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INDISPENSABLE    ORTHOPAEDICS 


INDISPENSABLE 
ORTHOPAEDICS 

A  HANDBOOK  FOR  PRACTITIONERS 


BY 

F.     C  A  LOT 


CHIEF   SURGEON   TO   THE    HOPITAL   ROTHSCHILD,    HOPITAL   CAZIN, 

HOPITAL   DU    DEPARTEMENT   DE   L'OISE,   INSTITUT 

ORTHOPEDIQUE   DE   BERCK.   ETC. 


TRANSLATED  FROM  THE  SIXTH  FRENCH  EDITION 

BY 

A.  H.  ROBINSON,  M.  D.,  M.R.C.S. 

AND 

LOUIS  NICOLE 


ILLUSTRATED 


VOL.   I 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1916 


-^,  T\")^l 


C 


Index  of  the  Coloured  Plates. 


PI.  I.  The  dilTerent  appearances  of  tuberculous  pus  and  the 

indications  to  be  drawn  from  them  with  regard  to  treat- 
ment and  prognosis 1^3 

PI.  11.  —  Cold  abscess  on  the  point  of  opening.  How  to  save  the 

skin?  (See  description  below  the  illustration) i53 

PI.  III.  —  The  same  (see  PI.  11).   The  skin  is  saved  (see  the  des- 
cription below  the  illustration) 133 

PI.  IV.  —  Suppurated  cervical  adenitis  (condition  on  arrival  at 

Berck) 88i 

PI.  Y.  The  same  as  PI.  IV.  —  After  our  treatment.  The  sup- 
purated adenitis  has  been  cured  without  a  scar 88 1 

PI.    VI.   _   Cervical   adenitis.   Unsightly  effects  produced  by 

operation ""^ 

PI.  VII.  —  Cervical  adenitis  (The  evil  effects  oi  abstention)  .    .      88i 

PI,  VIII.  —  Cervical  adenitis  (Even  when  a  fistula  exists,  do 

not  operate) 889 


ABini)(ii:i)   T\BLE   OF   GOMFNTS 

(For  I  In'  detailed  index,  a  real  recapitulation 
of  the  work  and  for  the  alphahelical  index,  see  pagea  i()G7  lo  1109.) 

Pkekvce.  —  J  lir  lli'valoi^iio,  or  tlio  six  conimanflmcuts  of  orthopir'dics. 

THREE  PRELIMINARY  CHAPTERS  ON  GENERAL  TECHNIQUE 

^"^''-  T.   Tethiiique  of  the  apparatus  (plaster  ami  celliilolilj.    .    .  () 

—  II.    A  word  upon  anaesthesia  in  orthopmdics io8 

III.    Technique    of    puncture   and    injection    in    tuherculosis 

a)  with  suppuration,  b)  dry,  c)  hslulous ii5 

SPECIAL   TECHNIQUE. 

i*^'  Part  :  —  Acquired  tuberculous  orthopoedic  affections. 

Chai'.         n  .   Indispensable  notions  on  the  prognosis  and  treatment  of 

external  tuberculoses igi 

—  V,   Pott's  disease 23q 

—  VI.   Hip  joint  disease 353 

—  \II.   White  swellings   .    . l^SQ 

a^-i  Part  :  —  Acquired  non-tuberculous  affections. 

Givp.       YIII.  Scoliosis  of  adolescents 56-r 

IX.  Round  back  and  lordosis. 6o3 

X.  Rickets.  Rickety  deviations. G08 

XI.  Genu  valgum  or  varum  of  the  adolescent.  Coxa  vara.    .  (1:40 

XII.  Tarsalgia  or  painful  flat-foot 0:^5 

XIII.  Infantile  paralysis  and  its  deviations GGo 

3nd  p^j(T  .  —  Congenital  orthopoedic  affections 
Chap.      XH  .   Congenital  luxation  of  the  hip-joint -n 

—  X^  .   Congenital  club-foot 82a 

—  XA'I.   Torticollis g-jg 

—  XVII.   Little's  disease 863 

4'^  Part":  —  or  Appendix. 
CiiAP.  XVIII.   Cervical  adenitis 881 

—  XIX.   Other  external   tuberculoses  (cold  abcess,  osteitis,  synovitis, 

spina   ventosa,    tuberculosis   of  the   testis    and   epididymis, 
tuberculosis  of   the  skin) "  ^q^ 

—  XX.   ^lultiple  tuberculosis 034 

—  XXI.    Syphilis  of  the  bones  and  articulations g'n 

—  XXII.   Treatment  of  acute  and  chronic  osteomyelitis qoa 

—  XXIII.    Practical  diagnosis  of  osteitis  or  of  chronic  arthritis   .    .      961) 

—  XXn  .  Some  malformations  of  the  hand  and  fingers 97^ 

—  XXV.    Some  malformations  of  the  foot  and  toes g8i 

—  XXM.   Additional    notes   on   tuberculosis,   fistuhe,    fractures   of 

the  neck  of  the  femur,  coxa  vara,  etc 992 

Calot.  —  Indispensable  orthopedics.  i 


PREFACE   TO   THE   6"   EDITION 

In  less  than  4  years  this  hook  has  reached  the  6"'  edition  and  has 
been  translated  into  5  languages. 

Is  it  not  a  proof  that  it  has  already  helped  French  and  foreign 
practitioners  and  that  it  may  still  further  help  them? 

We  have  doneour  best  to  make  it  do  so.  This  6"'  edition,  carefully 
revised,  has  been  enlarged  by  100  pages  and  100  figures  on  exter- 
nal tuberculosis,  fistulas,  the  preparation ^  of  the  liquids  and 
pastes  to  be  injected,  fractures  of  the  neck  of  the  femur,  coxa 
vara,  etc.  Besides,  over  one  hundred  of  the  original  illustrations  have 
been  replaced  by  as  many  new  ones,  clearer  and  more  explanatory. 
All  our  care  has  also  been  brought  to  bear  on  the  material  execution 
of  this  work  which  —  thanks  to  the  combined  efforts  of  our  pvibli- 
sher,  our  printer,  and  our  very  able  illustrator  D'  Fouchou-Lapcy- 
rade  —  has  been  brought  up,  we  think,  to  the  highest  possible  degree 
of  perfection  that  can  be  attained  at  the  present  time. 

We  hope  that  being  so  much  improved,  this  6"'  edition  will 
deserve,  more  even  than  the  preceding  ones,  the  favourable  reception 
given  to  our  book  bv  practitioners  all  over  the  world. 


PREFACE   TO    THE    5*''   EDITION 

This  5"'  edition  contains  nearly  ooo  pages  and  ooo  figures  more 
than  the  4"'>  without  counting  8  photos  in  colour. 

The  principal  additions  bear  on  the  technique  of  the  ajDparatus 
and  punctures,  which  we  have  been  careful  to  explain  in  a  clear  and 
detailed  manner  —  not  afraid  of  being  too  long  or  of  dwelling  on  too 
small  details.  For,  having  seen  at  work,  during  our  holiday 
courses,  several  hundreds  of  doctors  and  students,  we  are  convinced 
that  the  double  technique  (of  apparatus  and  punctures)  which  was 
thought  to  be  generally  known,  is  very  badly  understood  and  still 
Avorse  applied  —  with  a  few  rare  exceptions. 

And  for  any  one  who  does  not  begin  by  learning  thoroughly  the 
methods  of  making  the  plaster  and  of  practising  injection  it  is 
utterly  impossible  to  treat  successfully  any  of  the  diseases  described  in 
this  book. 

I.  According  to  the  metliod  of  our  assistant  D>"  Fouchet,  of  Berck. 


PUb^FACE  TO  THE   4''   EDITION 

Tlic  o"'  edition  of  this  work  has  received  from  the  medical  public 
Ihc  same  measure  ol'  success  as  the  lirsl  two. 

So  kind  a  reception  is,  for  the  author,  not  only  a  highly  valued 
reward  but  also  a  definite  encouragement  to  persevere  in  the  method 
he  has  choosen  in  explaining  the  orthopedic  techniques  which  are 
the  subject  of  this  book. 


PREFACE   TO   THE  3"^  EDITION 

Let  us  point  out  among  the  additions,  the  chapter  on  the  pro- 
gnosis and  treatment  of  external  tuberculosis  in  general,  and  on 
the  mentality  which  all  doctors  entrusted  with  these  treatments 
ought  to  have. 

The  object  pursued  now  and  always  by  the  author,  in  his  altera- 
tions and  additions  as  in  his  first  work,  is  to  provide  for  his  colleagues 
a  guide  sure  and  easy  to  follow  and  necessary  to  enable  them  to 
institute  and  successfully  complete  the  treatment  of  external  tuber- 
culosis and  of  orthopcedic  affections. 


PREFACE    TO    THE    2"'   EDITION 

This  2"''  edition,  following  so  rapidly  on  the  former,  cannot  show 
anv  noticeable  clian2:es. 

Nevertheless  everv  page  of  the  text  has  been  carefully  I'evised 
and  a  few  even  entirely  altered,  so  as  to  I'ender  even  clearer  the  expla- 
nations of  certain  especially  delicate  techniques. 

The  illustrations  have  been  enriched  by  3o  new  ones,  Avhile  about 
3o  of  the  old  have  been  replaced  by  others  more  explanatorv. 

This  shows  that  the  author  has  neglected  nothin"-  to  render  the 
book  still  more  Avorthy  of  the  favourable  reception  it  received  from 
the  whole  medical  press  and  from  practitioners. 


ALL    PRACTITIOERS    CAN    TREAT 


PREFACE  TO  THE  FIRST  EDITION 

Nearly  every  day  practitioners  are  consulted  for  hip  disease, 
Pott's  disease,  white  s^velling,  congenital  luxation  of  the  hip,  scoliosis, 
rickety  manifestations,  in  a  -word,  for  a  deviation,  congenital  or 
acquired. 

But  they  know  too  little  about  the  treatment  to  dare  to  institute 
it  or  to  be  able  to  apply  it  successfully. 

How  is  it  that  doctors  who  so  often  treat  fractures  and  traumatic 
luxations  do  not  dare,  or  are  unable  to  treat  orthopedic  affections 
which  are  not,  as  a  rule,  more  difficult  to  correct  and  to  maintain? 

It  is  because  they  have  not  learnt  to  do  it. 

True,  fifteen  or  twenty  years  ago,  or  even  only  ten  vears  ago, 
there  Avas  no  possibility  of  learning  it,  for  the  treatment  of  most  of 
these  affections  was  then  too  uncertain,  too  complex  or  even  absolutely 
non-existent. 

Congenital  luxation  of  the  hip,  for  instance,  was  still  the  one 
incurable  disease,  the  disgrace  of  surgery.  Hip  or  Pott's  diseases  Avith 
suppuration  ended  in  death.  These  three  diseases,  hopeless  yesterday, 
Ave  can  noAV  cure  Avith  certainty.  And  for  all  deviations  the  treat- 
ment has  been  so  much  improved  that  Ave  can  affirm  Avithout  much 
exaggeration  that  these  affections,  most  difficult  to  treat  barely 
12  or  15  years  ago,  yield  to  day  the  most  certain  and  lasting 
cures. 

Not  only  can  Ave  cure  them,  but  we  know  how  to  cure  them  by 
simple,  harmless  and  easily  applied  methods.  Their  treatment  no 
longer  implies  great  surgical  operations  nor  expensive  or  complicated 
mechanical  means. 

In  cases  of  hip  or  Pott's  disease  Avith  suppuration,  punctures  only 
are  required,  Avhich  punctures  are  certainly  easier  to  perform  than 
those  frequently  used  in  ti'eating  pleurisy. 

Incases  of  congenital  luxations  and  other  deviations,  the  correc- 
tion is  obtained  bv  simple  orthopaedic  manipulations  and  is  main- 
tained up  to  complete  cure  by  the  aid  of  a  Avell  made  «  plaster  » . 
Is  it  not  the  Avay  we  already  act  in  cases  of  fractures  or  traumatic 
luxations  ? 

Thus  the  treatment  of  orthopoedic  affections  has  become  acces- 
sible to  all  practitioners.  A  beneficient  revolution  which  carries  Avith 
it  the  most  practical  results;  for  3/4  of  the  patients,  unable  to  visit 
the  specialists  of  the  large  centres,  remained  until  noAv  Avholly  unat- 
tended. 


()i\iiioi'()ii)i(;  AFir:cTiONS  at  their  onset  ;> 

1)111  Kl  llicio  he  no  mlsuiidcrslandlng.  ^\  lien  I  say  \oucan  treat 
and  line  lliose  diseases,  this  is  absolutely  true  only  during  the  first 
period.  I.alcr  on>\liat  ^ou  can  do  is  limited  and,  in  nianv  cases,  \on 
are  powerless. 

I  should  never  advise  \ou  to  interl'ere  ■with  a  congenital  luxation 
1 5  vears  old,  or  w  ilh  hip  disease  or  a  gibhoslty  several  years  old.  The 
treatment  is  then  very  difficult,  indeed  almost  liopelesS;,  and  must 
alwavs  be  the  work  of  a  specialist. 

No.  What  I  require  from  practitioners  is  to  begin  treating 
these  diseases  from  their  commencement,  because  at  this  period 
the  evil  is  easy  to  cure. 

In  fact,  is  it  not  \ou,  the  family  doctor,  who  sees  his  patients  at 
the  onset?  Learn  then  how  to  utilise  this  priceless  advantage;  learn 
how  to  take  advantage  of  this  period  in  which  the  cure  is  relatively 
easy,  which  lasts  not  merely  for  a  few  days,  but  several  months,  and 
even,  in  the  case  of  certain  of  these  affections,  for  several  years. 

But,  above  all,  do  not  take  advantage  of  their  long  duration  to 
temporize.  ^^  by  should  you  wait?  A\hen  you  are  in  the  presence 
of  a  traumatic  luxation  or  of  a  fracture  do  vou  not  act  at  once? 

If  only  the  practitioners  aaIio  see  these  diseases  at  their  onset 
would  do  their  duty  ! 

But  how  arc  they  to  know  what  this  duty  is?... 

To  give  you  that  knowledge  is  the  purpose  of  this  book. 

^^  e  have  endeavoured  to  be  clear  and  concise  without  hoAvever 
omitting  any  necessary  or  useful  details.  On  every  page  figures 
illustrate  the  various  periods  of  the  treatment  in  such  a  way  that  any 
one  of  you  will  be  able  to  use  any  of  the  approved  methods,  any 
where,  even  without  a  special  installation  or  a  trained  assistant. 

I  hope  that,  thanks  to  this  guide,  all  doctors  so  desirous  will  hence- 
forth dare  to  institute  and  successfully  complete  the  treatment  of 
orthopoedic  affections. 

If  it  is  so,  the  lime  and  the  m  ork  spent  on  this  book  will  not  have 
been  w  asted  ' . 


I.  I  wish  to  thank  here  my  assistant  for  the  last  eight  rears  D''  Fouchou- 
Lapevrade,  whose  talent  for  drawing  and  deep  knowledge  of  the  suhject 
enables  me  to  illustrate  it  so  cleverlv. 


DIVISIONS  AND  PLAN  OF  THE  BOOK 


Three  preliminary  chapters  :  A.  Technique  of  the  apparatus.  — 
B.  Anaesthesia.  —  C.  Technique  of  punctures  and  injections  in  external 
tuberculosis. 

Part  I  :  Acquired  orthopcedic  affections,  of  tuberculous  origin.  — 
Pott's  disease.  —  Hip  disease.  —  White  swelling. 

Part  II  :  Acquired  orthopcedic  affections,  non  tuberculous.  — 
Scoliosis,  round  Lack,  lordosis.  —  Rickety  deviations.  —  Genu 
valgum.  —  Tarsalgia.  —  Infantile  paralysis. 

Part  III  :  Congenital  orthopcedic  affections .  —  Congenital  luxation 
of  the  hip.  —  Club  foot.  —  Torticollis.  —  Little's  disease. 

Part  I\  or  appendix  :  Cervical  adenitis.  —  Other  external 
tuberculoses  (cold  abcesses,  osteitis,  synovitis,  spina  ventosa.  Tuber- 
culosis of  the  testicle).  —  Multiple  tuberculosis.  —  Syphilis  of  the 
skeleton.  —  Osteomyelitis.  —  Diagnosis  of  osteitis  or  of  chronic 
arthritis . 

Additional  notes  :  i°  On  tuberculoses  :  a)  Is  it  advisable  to  ope- 
rate upon  them!'  b)  how  to  prepare  the  liquids  and  pastes  to  be 
injected,     c)  treatment  of  fistulae. 

2°  On  the  treatment  of  fractures  :  a)  of  the  patella,  h)  of  the 
olecranon-     c)  of  the  neck  of  the  femur. 

3°  On  coxa  vara  and  its  treatment. 


TlIK    IIEXALOGUE 

OR  THE  SIX  COMMANDMENTS  OF  ORTIIOPCHilDICS 


1.  Early  diagnosis. 

2.  /mmef//a/e  treatment. 

3.  Perseverance  in  treat  men  t. 

4.  The  preparation  of  well-jUling  plasters. 

5.  In  the  correction  of  tabercahiis  deformities,  to  reduce 
traumatism  to  a  minimum. 

6.  To  guard  against  operating  upon  the  tuberculoses;  never 
to  open  cold  abcesses  but  to  puncture  and  inject  them. 

I 

Early  diagnosis.  —  Whenever  a  child  is  presented  to  you 
with  a  loss  of  poAver  or  a  pain  seated  in  an}'  part  of  the  skeleton, 
you  should  never  neglect  to  inspect  and  examine  the  child 
completely  nude  (palpate,  apply  pressure,  ascertain  the  extent 
of  the  movements). 

II 

Immediate  treatment.  —  The  diagnosis  being  made,  do 
not  temporize;  commence  the  treatment  without  delay,  for  the 
malady  does  not  wait. 

Immediate  treatment  is  synonymous  (nearly  ahvays)  with 
easy  treatment  and  perfect  cure. 

Ill 

Perseverance  in  treatment.  —  Continue  the  treatment 
without  intermission  to  the  end;  the  end  may  be  protracted,  it 
may  be  one  or  even  several  years.  Warn  the  parents  of  this 
and  impress  upon  them  that,  just  as  in  your  own  case,  a 
strong  dose  of  patience  is  necessary  for  them. 


IV 

To  make  plasters  which  fit  well.  —  You  should  know 
hoAA"  to  adapt  a  plaster  Avhich  Avill  give  a  good  support  Avithout 
being  uncomfortable.  This  is  as  indispensable  a  matter  in 
orthopcedics  as  asepsis  is  in  surgery.  It  is  as  easy  to  make 
a  good  plaster  as  it  is  a  bad  one,  just  as  it  is  as  easy  for  the 
practitioner  to  be  aseptic  as  septic. 


Avoid  every  useless  traumatism.  —  In  the  correction 
of  tuberculous  deformities,  one  should  proceed  gently  and  rather 
by  set  stages.  It  is  more  necessary  here  than  in  other  defor- 
mities, in  order  to  prevent  all  danger  of  generalized  tuber- 
culosis. 

VI 

To  guard  against  operating  on  the  tuberculoses.  — 
Never  open  a  focus  nor  leave  it  to  open.  —  If  the  tuber- 
culous focus  has  suppurated.  —  if  an  abcess  has  formed,  a 
gland  has  broken  down,  an  osteo-arthritis  suppurated  —  punc- 
ture and  inject. 

If  the  focus  has  not  suppurated,  and  is  easily  accessible 
(this  is  true  for  all  external  tuberculoses  except  Pott's  disease), 
make,  in  the  focus  of  these  torpid  lesions,  modifying  injections, 
to  produce  or  to  hasten  the  hardening  or  softening,  after  which 
you  puncture  as  in  the  first  case. 

Remember  that,  in  tuberculosis,  operation  rarely  cures, 
it  often  aggravates  and  always  mutilates;  whilst  punc- 
tures and  injections  are  a  sure  treatment,  harmless  and 
practical. 


THREE  PRELlMlNArvY  CHAPTERS  ON  GENERAL  TECHNIQUE 

I"  In  orthopcedics',  those  will  have  ihc  best  results  a\ ho 
know  how  lo  make  the  best  apparatus. 

2"  In  the  external  tuberculoses,  those  will  have  the 
best  results  A\ho  know  best  how  to  make  punctures  and 
injections. 

AMience  the  necessity  of  commencing  by  a  careful  study  oi 
the  two  techniques  :  of  apparatus  and  of  punctures. 

And  as  a  large  number  of  deformities  cannot  be  corrected 
without  chloroform,  we  shall  study  in  the  third  preliminary 
chapter,  this  very  briefly,  the  practice  of  anaesthetics. 


CHAPTER  FIRST 
THE  APPARATUS 

Every  doctor  should  know  how  to  make  a  plaster  appa- 
ratus. It  is  as  necessary  —  and  even  more  often  necessary  — 
than  to  know  how   to  arrest  a  hemorrhage. 

Without  an  apparatus  it  is  impossible  to  treat  a  fracture,  an 
arthritis,  certain  luxations  or  certain  grave  traumatisms,  etc.,  etc. 

This  applies  to  all  general  practitioners. 

But  what  shall  we  say  as  to  apparatus,  for  those  specially 
interested  in  orthopedics?  Without  apparatus  one  can  do 
nothing,  or  next  to  nothing.  AVithout  apparatus  one  can 
neither  prevent  nor  arrest  nor  correct  a  deformity. 

You  can  judge  of  the  skill  of  the  orthopedic  surgeon  by  the 

I .  And  one  may  add  :  in  fractures  and  most  ajjcclions  of  the  skeleton. 


lO  APPARATUS    >fECESSARY    FOR    ALL    PRACTITIOERS 

apparatus  he  makes  use  of.      "  Show  me  your  apparatus  and  I 
Avill  tell  you  Avhat  you  are. 

I 
THE  PLASTER  APPARATUS 

Plaster   apparatus   are   the   best,  and    one    may   add   that 
plaster  suffices  for  everything  and  nothing  can  replace  it. 


Fig.   I.  —  ^yp^  of*  plaster  apparatus  :  this  is  the  apparatus  one    applies   for   tibio- 
tarsal  arthritis,  and  for  (vaclures  of  the  leg. 


Plaster  is  an  object  of  prime  necessity,  and  practitioners 
should  never  set  out  on  their  daily   rounds  without  having  a 


PLASTI'U    AI'I'AIUTl  S 


supply  of  a  few  kilos.  (It  is  jusl  as  imporlanl  as  an  artery 
forcej)s,  a  knife,  a  needle,  sutures,  a  bottle  of  chloroform,  a 
m itl w  ifery  forceps . . . ) 

By  itself,  plaster  alloAvs  of  the  securing  different  parts  of  the 
body  hi  ^vhatever  position  desired.  For  we  arc  able  to  maintain 
that  position  for  (he  few  minutes  required  for  the  setting  of  the 
plaster,  but  Ave  cannot  do  this  for  the  long  hours  ^vhich  are 
required  to  dry  any  other  substance  than  plaster  :  silicate  of 
potash  for  instance. 

Plaster,  because  it  adapts  itself  as  Ave  Avish  it  over  any  part 
of  the  body  Avill  give  us  results  very  superior  to  all  the  splints 
in  metal  or  in  Avood,  including  the  Bonnet  splint  or  the  appa- 
ratus of  Scultet,  AAhich  is,  besides,  much  more  difficult  to 
fashion  than  a  good  plaster. 

In  a  Avord,  Avith  plaster,  every  one  of  you  can  manage  to 
make  on  the  spot,  alone,  Avithout  the  aid  of  any  mechanician 
or  Avorking  orthopedist,  the  best  apparatus  Avhich  can  be  (for 
fractures  or  injuries,  or  orthopedic  affections). 

And  I  can  promise  you  that  you  Avill  be  able  to  make  plas- 
ters perfect,  homogeneous,  firm,  accurate,  comfortable  and  neat, 
if  you  will  folloAv  very  faithfully  the  directions  Avhich  I  am 
going  to  giA'e  in  this  chapter. 

In  the  first  part  of  the  chapter  (Avhich  you  should  read 
each  time  you  make  a  plaster),  Ave  have  put  together  all  the 
indispensable  notions.  In  the  second  part  (Avhich  you  should 
read  AA'henever  you  have  the  leisure),  you  Avill  hnd  all  the  com- 
plementary details  Avhich  you  can  desire  of  the  technique  of 
plaster  apparatus. 


INDISPENSABLE  NOTIONS  ON  THE  PREPARATION 
OF  A  PLASTER 


SUMMARY 


One  should  prefer,  even  for  the  treatment  of  fracture,  circular  plas, 
ters  which  fit  hetter,  are  more  agreeahle  to  the  patient  and  easier  to  make 
than  splints. 

In  order  to  watch  over  the  affected  parts,  in  a  circular  apparatus,  it  is 
sufficient  to  make  an  opening  over  those  points,  or  to  convert  the  plaster 
into  a  hivalve. 

To  ensure  the  good  nutrition  of  the  memher  under  treatment,  it  is 
sufficient  to  be  assured  of  the  good  nutrition  of  the  extremities  of  the  toes  or 
of  the  fingers,  which  should  always  be  left  exposed  beyond  the  apparatus. 

A  plaster  is  prepared  with  muslin  strips  impregnated  with  plaster  paste 
and  applied  entirely  round  the  region  of  the  body,  covered  with  a  casing  of 
soft  tissue. 

One  must  therefore  procure  :  first  a  closely  fitting  casing,  secondly  some 
muslin,  tlrirdly  some  plaster. 

The  casing  is  of  cotton  :  jersey,  sock,  stocking  or  sleeve  of  a  jersey  — 
according  to  the  region. 

This  lining  is  always  thinner  and  more  even  than  cotton  wool.  It  is  only 
in  default  of  such  a  casing  that  one  ■would  use  Cotton  wool,  taking  great  care 
to  apply  it  in  a  layer  as  even  and  as  thin  as  possible  (of  a  thickness  of  not 
more  than  i  or  2  mm). 

The  plaster  bandages  are  strips  of  muslin  about  5  metres  long  and 
1 5  cm.  wide,  which  have  been  impregnated  with  plaster  : 

a)  Either  they  are  steeped  at  the  time  in  plaster  paste  made  with 
5  parts  of  plaster  and  3  parts  of  water,  cold,  without  salt. 

b)  Or  sprinkled  a  little  before-hand  (one  or  few  hours  before)  with  dry 
plaster  in  the  proportion  of  60  grammes  of  plaster  for  each  metre  of  bandage; 
these  strips  are  then  soaked  in  cold  water  a  few  minutes  before  being  used. 

To  prepare  a  firm  apparatus  it  is  Avell  to  insert  a  support  of  «  attelles  »,  or 
strengthening  pieces,  between  the  layers  of  the  bandage.  These  attelles  are 
simply  pieces  of  muslin  cut  beforehand  and  soaked  for  a  minute  or  two, 
before  being  used,  in  the  same  cream  as  the  strips. 


IMH^^PENSMUi:     N..nnNS    ..>     TllK     I'KKl'A  U  U  K  .N     ..^     PI.ASI  KK  I  :^ 

TlK...  «  alU.llos  .  .llHT,.  an.  tun  nf  II.mu)  have  a  length  cciual  I.,  that 
of  the  apparatus,  a  hnsultl,  0,,...!  1.  l.aU  U.e  greatest  crcumfcrencc  of  the 
apparatu  an.l  a  thickness  of  one.  two  or  even  three  sheet  o  mushn.  accor- 
d  n^  as  the  plaster  is  a  small  or  a  large  one,  and  as  U  .s    or  a  ehjld  or  an  aJu  1. 

It  it  is  a  pla.l,..-  fnr  the  arm,  .hich  ought  to  inchule  the  shoulder  g.rdle, 
or  a  plaster  lor  the  lower  extremity  which  shoul.l  include  the  pdvis,  a 
,Ulnl  attelle  is  introduced  in  the  form  of  a  belt,  overlappu.g  th.  u,.,,-,- 
mar-in  of  Ihc  two  others. 

The  technique  of  the  apparatus. 

Suppose  YOU  have  to  make  a  plaster  for- the  leg  _ 

The  leg,  beeng  covered  with  a  easing,  is  placed  xn  position  an  assistant 
hokUr^  it  and  raising  it  by  the  foot.  You  apply  the  first  plaster  stnp, 
be  nnh-  at  the  toes  and  the  foot,  in  circular  turns  overlappmg  one  third, 
withou  making  reverses,  .vhich  are  unnecessary.  Take  care  to  apply  tbe 
t  ip:  «)  exactly;  6,  without  pressure;  a  flattening  .t  well  so  as  not 
Tleave  creases.  You  ascend  as  far  as  the  upper  extremity  of  the  apparatus, 
where  you  cut  short  Ihe  strip   if  it  is  not  used  up.  „     ,    , 

OvJr  this  first  la  er  of  turns  of  strips,  attelles  well  smoothed  down 
applied,   one   in    fro^t,    another,  behind.      And,  over   the   attelles    you   apply 
fuither   turns  of  strips,    making  thus  a  third  or  fourth  covering,  according 
as  the  case  is  a  child  or  an  adult. 

Between    the    dilferent     lavers    of    the    apparatus    and   over    the  la.t   one 
some  plaster  paste,  one  to  two  centimetres  in  thickness,  is  applied. 
And  that  is  all. 

Then  verify  and  rectifv,  if  necessary,  the  position  of  the  limb  ;  model 
the  plaster  over  the  osseous\,romlnences  of  the  part  ^y ,^''^!^'^^' ^'^l^'^. 
diatly  upon,  but  aroand  those  prominences;  maintain  it  thus  until  the 
complete  setlimj  of  the  plaster. 

A  cniarler  of  an  hour  later,  trim  the   plaster,  strengthen    it   if  need  he. 
Be  ore  leaving  the  house,  always  make  sure  of  the  good  nutrition 
of  the  toe'  which   will    bo  a  guarantee  of    the  good    nutrition   ot   the   entue 
limb. 

We  will  take  for  a  tvpe  of  our  description  the  construction 
of  a  plaster  for  the  leg  beg- inning-  from  the  toes  and  reaching 
as  far  as  the  lower  third  of  the  thigh. 

It  is  the  apparatus  which  should  be  used  for  fractures  oi 
the  lee-  and  for  arlhrilis  of  the  inslep. 

It%hould  reach  as  far  as  above  the  knee-joint  because, 
to  immobilize  well  a  portion  of  a  limb,  it  is  necessary  always 
to  immobilize  at  the  same  time  as  the  segment,  at  least  ttic 
two  adjacent  arlicnlalions. 


1 4       WHAT    IS    NECESSARY    IN    ORDER    TO    CONSTRUCT    A    PLASTER 

We  ^\l\\  noAv  give,  a  propos  of  this  apparatus,  all  that  part 
of  the  technique  which  is  common  lo  all  plaster  apparatus, 
whatever  they  may  be.  As  to  the  peculiarities  of  each  region, 
you  will  find  them  indicated  in  the  chapters  devoted  to  the 
different  diseases  (for  the  plaster  corset,  see  the  chapter  on  Pott's 
disease,  and  for  the  large  plaster  for  the  lower  limb,  the  chapter 
on  hip  disease). 

A.   —  WHAT  IT  IS  NECESSARY  TO  OBTAIN 

Three  things  :  a)  a  casing  of  soft  tissue;  b)  some  plaster; 
c)  some  muslin. 

a.  The  protecting  case'.  —  "^  ou  may  find  this  everyAvhere; 
it  should  be  simply  a  large  stocking  reaching  up  to  the  lower 


Fig.  2.  —  The  casing  of  soft  lissae   (jersey  or   "   tube  '")    which   protects    the  skin 
against  direct  contact  with  tlie  plaster. 

third  of  the  thigh,  or  heller  two  sleeves  of  a  jersey  applied  end 
to  end,  or  even  a  "  lube  "  of  soft  tissue. 

I.  ^luch  iirefcrable  lo  cotton  aaooI,  as  "\ve  ^^  ill  show,  p.  62. 


1°  A   cAsiNc.    :>"  <(t\\\:   i'i.ASTi;n,    .')"   somi;    mi -i.i\  i5 

If  llie  tissue  of  the  «  tube  »  or  casing  is  very  thin  you 
cniplov  two,   ihe  one  over  the  other. 

If  the  lube  be  too  large,  make  it  lit  at  once  by  means  of 
sewing. 

]))  The  Piaster.  —  This  is  A\hite  plaster  of  Paiis,  fine  and 
homogeneous,  soft  to  the  touch  as  starch  powder. 

Preserve  it  from  moisture,  and  even  from  the  air,  in  a 
glass  jar,  or  in  a  tin  box,  hermetically  closed;  because  the 
plaster  deteriorates,  that  is  to  say,  it  becomes  moist  in  time, 
if  kept  in  a  bag.  even  in  a  place  which  does  not  appear  to  be 
damp. 

If  you  take  two  samples  of  good  plaster  obtained  from  dif- 
ferent sources,  they  may  not  both  set  in  the  same  time ;  this 
depends  upon  their  degree  of  baking.  The  moment  of  setting 
may  vary  very  markedly  in  the  one  sample  and  the  other ;  and 
it  is  to  prevent  disappointment  that  I  advise  you  always  to  test 
the  sample  of  plaster  you  are  using,  belore  pieparins'  vour 
apparatus. 

In  order  to  do  this,  place  in  a  bowl  five  spoonsful  of  j)laster 
to  three  of  Avater  (these  are  the  ordinary  proportions),  mix 
them  AA"ell  together  and  note  hoAV  long  this  (f  plaster  cream  » 
lakes  to  set. 

If  you  cannot  obtain  the  white  plaster  of  Paris,  you  may 
use  the  grey  (as  used  by  plasterers),  coarser,  often  as 
gritty  as  fine  sand.  To  ensure  the  best  chance  of  its  being 
perfectly  dry,  take  it  from  the  middle  of  the  sack  and  sift  it, 
if  it  is  not  homogeneous.  This  common  plaster  should  be 
made  of  a  thicker  consistence  than  the  Avhite  plaster;  you 
must  put  a  third  more  plaster  to  the  same  cpiantity  of  Avater 
—  remembering  that  it  requires  a  third  more  time  to  set  than 
the  Avhite  plaster  of  Paris.  You  can  make  good  apparatus  Avith 
this  common  plaster,  though  less  pleasing,  provided  it  has  not 
deteriorated. 


1 6  TECHXIQUE    OF    PLASTER    APPARATUS. 

Finally,  suppose  in  a  case  of  extreme  urgency,  you  have 
only  at  hand  plaster  Avhich  is  a  little  deteriorated,  that  is  to  say 
hydrated  (white  or  grey  plaster) ;  you  could  dehydrate  it  and 
give  it  back  its  virtue  by  baking  it  for  ten  or  fifteen  minutes,  in 
an  ordinary  oven  and  in  an  open  receptacle  S  until  no  more 
water  vapour  is  disengaged. 

The  quantity  of  plaster  required.  —  Take  rather  too 
much;  say  2  kilos  for  a  child  of  ten  or  tAvelve  years  of  age,  and 
three  for  an  adult  (for  a  leg  apparatus). 

c.  Muslin.  — ■  Ask  at  the  stores  for  stiff  muslin  number 
y  or  8,  that  is,  with  7  or  8  threads  to  the  square  centimetre 
(v.  fig._  3). 

This  N°  8  will  not  be  too  close  nor  too  loose ;  that  is  the 


Fig,   3.  —  The  stiff  muslin  N°    8   used  in   making  the    strips  and   the  attelles. 
(8  threads  per  centimetre.) 

kind  of  muslin  used  by  dressmakers  for  making  the  patterns  for 
dresses. 

I.  Wliere  can  we  procure  good  plaster?  Tliis  practical  information  we  are 
often  asked  for  by  practitioners.  Well,  you  may  obtain  the  white  plaster  of 
Paris  at  pharmacists,  and  at  some  moulders;  I  dare  not  say  at  all,  because 
some  use  in  place  of  plaster,  alabaster,  which  does  not  fulfil  exactly  the  condi- 
tions required. 


riir.    MISI.IN    IS    CLT    INTO    STRIPS    AND     "     ATTELKES  17 

Procure  more  llian  \ou  rcall\  want. 

Take  7  or  8  metres  of  the  orJinar\  widlli.  which  is  Go  or 
70  cm.;  five  metres  will  be  sulficient  ibr  a  child  ol"  10  or 
I  a  years. 

Failing  stilT  muslin,  should  the  case  be  urgent,  you  will 
find  plenty  oi'  old  curtains,  cast  off  sheets,  from  which  you 
can  cut  off  strips  of  12  cm.  in  width,  and  you  can  join  them 
together  end  to  end,  w  ith  fme  stitchint*-  so  as  nut  to  lea\e  any 
ridges. 

Lastly,  you  should  have  two  or  three  basins,  some  cold 
water  without  salt,  scissors,  and  a  knife. 

And  ask  also  for  one  or  two  large  sheets,  A\hich  you  can 
arrange  so  as  to  prevent  the  spotting  and  soiling  of  the  carpet, 
the  bed.  or  the  floor,  w  ith  plaster. 

B.   —    ASSISTANTS 

You  should  have  two  assistants  (one  will  be  sufficient  at  a 
push),  to  make  the  apparatus  for  the  leg. 

The  assistants  may  not  be  medical  men,  but  simply  two  mem- 
bers of  the  family;  you  should  make  them  understand  hoAV 
to  follow   well  your   instructions  and   assist  your  movements. 

With  these  assistants,  you  should  commence  by  cutting 
vour  strips  and  attelles  out  of  the  large  piece  of  muslin. 

C.   —   PREPARATION  OF  THE  STRIPS   AND  ATTELLES 

a.  The  strips.  You  separate,  by  tearing  with  Nour  fingers, 
a  strip  of  muslin  having  the  folloAving  dimensions  : 

Breadth  :  12  to  10  centimetres. 

Length  :  5  metres. 

These  are  the  ordinary  dimensions  of  the  plastered  strips. 

Then  vou  take  a  second  and  a  third  strip  from  the  loll  of 
muslin. 

Cai.ot.   —  Indispensable  oiihopedics.  a 


lO  TECHNIQUE     OF    PLASTER    APPARATUS 

The  number  of  the  strips  naturally  varies  with  the  build  of 
'the  subject;  for  a  child  under  7  or  8  years,  one  strip  may  be 
sufficient;  for  a  child  from  8  to  i4  years,  two  strips;  for  an 
adult,  three  strips  (always  for  a  leg  apparatus). 

h.  The  attelles.  —  These  are  not  indispensable,  the  appa- 
ratus could  be  made  Avith  strips  alone  but  it  is  belter  to  incor- 
porate attelles  or  strengthening  pieces  between  the  layers  of  the 
strips.  With  these  "  attelles  "  the  apparatus  are  firmer, 
more  easily  constructed,  more  quickly  made,  more  compact, 
more  homogeneous,  than  those  made  with  strips  alone,  especially 
if  one  employs  slrips  which  have  been  sprinkled  with  plaster 
beforehand. 

The  attelles  are  cut  from  the  remains  of  the  piece  of  muslin 
(after  having  taken  the  strips  from  it). 

The  number  of  attelles  :  tAvo  for  each  leg  apparatus. 
The  Dimensions  :  the  same  for  the  two  attelles,  namely  : 
Length,   equal   to    that   which    the  apparatus   should  have 
(measuring  from  the  upper  extremity,   above  the  knee,   to  the 
heel,  and  adding  the  length  of  the  sole  of  the  foot). 

Breadth,  equal  to  half  the  greatest  circumference  of  the 
region  to  be  covered  (that  is  to  say,  here,  half  the  circumference 
of  the  calf). 

Thickness,  that  of  two  sheets  of  muslin.  It  is  unnecessary 
to  sew  the  two  sheets  together;  folded  one  on  the  other  and 
flattened  with  the  hand,  they  will  remain  in  contact. 

Here  then,  are  your  slrips  and  atlelles  cut  out  of  the  piece 
of  muslin.  But  you  will  not  plaster  them  until  you  have  pre- 
pared the  affected  limb  and  placed  it  in  position. 

D.    —   PREPARATION  OF  THE  PATIENT 

The  patient  remains  in  bed,  or  better,  is  carried  on  to  a 

table. 


I'UEI'AUATIO.N    Ol'    THE    PATIENT  i 


0 


The  lANO  legs  are  brought  over  the  edge  of  the  table.  The 
sound  leg  need  not  be  held,  the  sound  foot  rests  on  a  chair. 

The  Toilet  of  the  Skin.  The  skin  is  washed  with  a 
tampon  damped  Avith  alcohol  or  ether,  and  is  lightly  sprinkled 
with  sterilized  talc.  If  there  is  a  wound,  one  covers  it  ^ith  a 
square  of  aseptic  gauze,  taking  note  of  the  place,  (o  make  there 
an  opening  in  the  plaster  a  few  minutes  after  its  construction 
—  in  view  of  the  dressing  required  afterwards. 

a.  Placing  in  Position. 

Two  cases  : 

Either  the  limb  is  already  in  good  position  or,  it  may  be 
placed  so  at  once  (arthritis  without  deformity,  fractures  without 
displacement,  or  where  reduction  is  verv  easv). 

Or  else,  the  limb  is  in  bad  position  and  its  correction 
requires  some  time,  and  often  even  the  use  of  chloroform  (frac- 
tures or  recalcitrant  orthopedic  deformities). 

As  for  the  movements  required  for  correction,  this  is  not  ihe 
place  to  describe  them,  they  will  be  indicated  a  propos  of  each 
deformity. 

AA  hen  this  correction  has  been  made,  it  Avill  be  maintained 
by  an  assistant  at  the  bottom  of  the  table,  Avho  will  seize  the 
foot  and  pull  it  more  or  less,  as  the  case  requires. 

If  a  very  steady,  strong  traction  is  needed  a  second  assistant 
may  make  counter  extension  by  holding  the  thigh  or  the  knee 
with  both  hands  and  pulhng  towards  the  upper  part  of  the 
thigh. 

Manner  of  holding  the  foot.  —  The  right  hand  of  the 
assistant  grasps  the  fore  part  of  the  foot  firmly,  the  palm  of  the 
hand  being  applied  to  the  sole,  and  the  fingers  on  the  dorsal 
aspect.  The  left  hand  seizes  the  heel  and  the  instep,  the  palm 
embracing  the  projecting  heel,  the  fingers  on  the  lateral  aspect. 

Position  of  the  foot.  —  i'\  It  should  be  held  at  90"  of 
flexion  upon  the  leg.  or  even  at  a  slightly  acute  angle,  of  80" 


•20 


TECHNIQUE    OF   PLASTER    APPARATUS 


for  instance;  2"''.  The  middle  of  the  second  toe  must  be  in 
a  line  with  the  crest  of  the  tibia.  —  Sometimes  in  order  to 
obtain  a  hyper-correction  the  foot  is  carried  a  httle  to  the  inner 
side,  or  a  httle  to  the  outer,  in  an  inverse  direction  to  the  defor- 
mity it  is  desired  to  overcome;  3"'.  The  heel  should  be  made 
to  present  its  normal  projection  behind  (compare  it  with  the 
sound  side). 

b.   Enclosing    the   limb  with    a   casing    of   soft  tissue. 


Fig.  ^i.  —  One  passes  the  fourreau  or  "  tube  "  as  one  puts  on  anew  stocking,  folding 
it  back.  Whilst  an  assistant  hokls  the  Toot  by  tlie  heel,  one  commences  by  cover- 
ina,  the  forefoot  with  this  folded  "  tube  ". 


To  prevent  any  discomfort  to  the  patient  while  ihe  fourreau 
is  passed  on  the  foot,  the  assistant  holds  the  heel  with  one  or 
both  hands,  and  pulls  toAvards  him  while  the  fourreau  is  passed 
over  the  toes,  gathered  up  and  folded  (v.  fig.  /|);  then  the 
fourreau  having  passed  as  far  as  the  base  of  the  toes,  the  assis- 
tant leaves  the  heel  and  takes  hold  of  the  toes  and  instep  Avith 
both  hands,   while  the   fourreau   is   passed  over  the  heel   anp 


now    Id  PI  r   ()\    I  in:   casing  of   soft   tissik 


21 


k 

Fig.  5.  —  The  tube  OQce  passed  over  the  foot,  the  assistant  leaves  the  heel  and  seizes 
the  forefoot,  then,  again,  the  heel.  The  fourreau  is  unfolded  to  ensheath  succes- 
sively the  leg,  the  knee  and  the  lower  part  of  the  thigh. 


Fig.  C.  —  Placing   the  patient  in  position. 


22 


TECimiQUE   OF   PLASTER    APPARATUS 


on  to  the  leg  (v.  fig.  5).  The  fourreau  being  in  place,  the 
assistant  takes  hold  again  of  the  heel  and  instep. 

The  upper  border  of  the  fourreau  is  held  by  a  second  assis- 
tant, or  by  the  patient  himself,  seated. 

If  instead  of  a  tube,  a  stocking  is  used,  its  lo^Yer  end  should 
be  split  to  allow  of  inspection  of  the  naked  toes. 

E.    —    THE  PLASTERING  OF  THE  MUSLIN  STRIPS 
AND  "  ATTELLES  " 

This  is  done  by  simply  steeping  the  strips  and  attelles  in 
the  Plaster  cream  ^ 


Fig.   rj    —  Method  of  preparing  the  best  plastered    strips       The   strip  of  stiff  muslin 
is  rolled  in  the  plaster  cream  (three  cups  of  water  to  five  of  plaster). 

a.  Composition  of  the  Plaster  cream. 

Plaster  is  mixed  with  water  in  the  following  proportions  : 
five  cups  of  plaster  to  three  of  cold  water,  without  salt;  there- 
fore, no  hot  water  nor  salt,  with  which  the  plaster  sets  too 
quickly;  with  those  also  the  apparatus  is  too  brittle  and 
friable. 


I.  Cover  your  liand  with  vaseline  before  doing  this. 


rLASTEUlNG    THE    STUU'S    AM)    ATTKLLES  a3 

The  quantity  of  the  cream  lo  be  |)repareJ  (for  aa  appa- 
ralus  for  llic  leg)  is  one  cup  and  a  half  of  Avaler  lo  two  and  a 
half  cups  of  plaster  for  a  child;  three  cups  of  water  and  five  cups 
of  plaster  for  an  adult.  J'liis  (|uanlll\  suffices  ampl\  lor  an 
ordinary  apparatus  for  the  leg. 

If,  by  any  chance,  you  run  short  of  ihc  plaster  cream  in 
the  course  of  constructing  the  apparatus,  you  mav  prepare 
more  at  once  in  another  basin,  or,  if  you  like,  in  the  same  one, 
but  after  having  thoroughly  washed  it,  for  the  new  cream  musi 
not  be  mixed  Avith  the  debris  remaining  from  the  preceding 
mixture ' . 

How  ought  one  to  proceed  to  prepare  the  Plaster  cream  ? 
Into  a  hand  basin,  first  pour  all  the  water  required,  then  all  the 
plaster  needed.  Stir  up  at  once,  rapidly  and  thoroughly,  so 
as  to  make  a  homogeneous  cream,  without  leaving  any  grit. 
This  mixing  of  the  plaster  requires  hardly  i5  to  20  seconds. 

b.   Impregnation  of  the  strips  (v.  fig.  -). 

Immediately  the  cream  is  ready  you  steep  the  unrolled  strip 
or  strips  of  muslin  in  it.  which  allows  of  their  being-impregnated 
"  uniformly  "  and  quickly  Avith  plaster. 

The  first  strip  being  impregnated,  you  quickly  roll  it  up. 
and  the  others  Avill  be  rolled  up  in  the  same  way  by"  your  assis- 
tants Avho  have  seen  how  to  do  it.  Aon  tighten  each  turn  as 
you  Avould  in  rolling  a  bandage  of  ordinary  linen,  or  of  linen 

I.  Mix  ttie  two  pastes.''  never  I  nor  will  you  ever  add  water  lo  a  cream 
which  is  too  thick,  and  has  been  mixed  several  minutes;  this  would  "drown  " 
and  "  kill  "  the  plaster,  one  would  only  have  "  dead  "  plaster  ^to  use  the 
technical  term).       One  would  •'  turn  "  the  cream. 

To  add  plaster  to  a  cream  too  thin  is  not  so  bad  as  to  add  aa  aler  to  a  cream 
which  is  too  thick,  nevertheless  it  is  undesirable  and  should  be  avoided. 

^\  hen  you  find,  after  a  few  minutes,  that  you  have  not  sufficient  cream, 
you  will  make  a  neAV  supply,  in  a  perfectly  clean  basin.  In  the  same 
way,  if  it  ever  happens  after  a  few  minutes,  tliat  you  find  your  cream  is 
too  thin,  or  too  thick,  throw  it  away,  wash  out  the  basin  and  make  a  new 
supply,  which  should  be  more  or  less  charged  with  plaster  as  may  be  requi- 
red. 


24 


TECIOIQUE    OF    PLASTER    APPARATUS 


soaked  in  silicate  of  potash,  Avhich  nearly  all  of  you  have  lear- 
ned to  do.  In  a  word,  do  not  tighten  too  much,  nor  too 
little;  and  the  strips  Avill  thus  retain  just  the  quantity  of  plaster 
you  Avisli,  and  you  Avill  be  able  to  apply  them  one  after  the 
other  Avilhout  having  to  squeeze  them,  or  at  any  rate  very  little. 


Fig  8.  —  In  the  basin  on  llie  right,  a  bandage  has  been  rolled  in  the  crem,  in  that 
on  the  left,  the  plaster  intended  for  the  preparation  of  attelles  is  being  stirred. 

The  rolled  strips  are  left  in  the  basin  while  you  go  on  plas- 
tering the  attelles  (Fig.  8). 


c.   Impregnation  of  the  Attelles  (v.  fig.  9). 

In  a  second  basin,  in  Avhich  you  have  prepared  a  fresh 
supply  of  cream,  or  have  poured  the  excess  of  that  prepared  for 
the  strips,  but  which  you  have  not  used,  you  soak  the  attelles, 
one  by  one,  folding  and  thoroughly  impregnating  them. 

The  impregnation  of  the  attelles  requires  scarcely  a  few 
seconds  (say,  1 5  to  20  seconds). 

As  soon  as  the  strips  and  attelles  are  impregnated,  they 
should  be  applied.  But,  before  indicating  the  method  of  making 
this  application,  we  ought  to  explain  a  second  method  of  prepa- 


IM.VSTKUIMi    sriUP^    I'UEI'AIIEI)     UKl'dlU- II.VM) 


20 


ring  ihc  plaster  strips  \vliich  is  found  recommended  everywhere  : 
lh(>  sprinklinjir  of  llic  strips  -with  dr\  |)lasler,  beforehand. 

Plaster  strips,  prepared  beforehand. 

This  procedure  consists  in  iin[jrciinalin'j  beforehand  the  muslin  strips  ivUli 
ilrv  phtghT.  placing  tliem  artcr\\ar(ls  in  reserve,  several  davs  or  several  ^\eeks. 


9.  —  Method  of  soaking  the  attelles  in  the  cream  :  they  should   be  impregnate  1 
a  little  at  a  time,  piece  by  piece,  and  not  all  at  once  and  en  masse. 


until  they    are    wanted   :    it  is   llien   sufficient    to   dip  them  in  Abater  a  feu- 
minutes  before  applying  them. 

les,  but  remember  it  is  difficult  enough  for  those  not  accustomed  to 
it,  to  prepare  in  this  way  bandages  having  the  desired  charge  cf 
plaster. 

Now,  if  too  much  plastered,  they  will  not  allow  of  being  well  "  soaked 
and  will  retain  in  places  gritty  particles  of  hard  plaster;  when  there  is  not 
sufficient  plaster,  the  apparatus  will  be  soft  and  friable,  like  a  •'  giileau  feuil- 
lete  ".  More  than  that,  the  plastered  strips  prepared  more  or  less  a  long 
lime  beforehand,  run  the  risk  of  decomposing,  that  is  to  say,  of  deteriorating 
and  becoming  h>drated. 

And  this  is  the  reason  \a  hy  I  advise  you,  in  a  general  way,  to  prepare 
your  strips  in  the  manner  first  described  (in  the  cream)  «hich  is  moreover 
the  simplest  and  surest  method  of  obtaining  homogeneous  and  firm  appa- 
ratus. 


26 


TECHMQUE    OF    PLASTER    APPARATUS 


Xohvithstanding,  I  do  not  absolutely  prohibit  vour  having  recourse  to  the 
second  method;  there  is  one  case  even  where  it  would  be  better  to  use  it. 
This  case  is  when,  having  need  of  a  large  number  of  strips  in  order  to  make 
a  large  apparatus  for  Pott's  disease  or  Coxitis,  you  have  not  at  your  side  three 
or  four  capable  assistants,  who  after  having  seen  you  plaster  the  first  bandage 


Fisf.  lo.  —  To  prepare  plastered  strips  Leioreliand,  one  sprinkles  60  to  70  grammes 
of  plaster  in  powder  over  each  metre  of  muslin  ( i5  cm  wide);  one  rolls  the  strip 
with  the  right  hand  whilst   the  left  hand  spreads  the  plaster 


in  the  cream,  planter  all  the  others,  whilst  you  yourself  apply  the  first  strip 
(and  all  the  following  ones). 

If  vou  are  alone  in  making  such  large  plasters  or,  if  you  have  only  one 
assistant,  vou  run  the  risk  of  being  much  retarded  by  this  preliminary  prepa- 
ration of  all  the  plastered  strips  required,  and  of  finding,  after  having  plas- 
tered the  last,  that  the  first  one  in  the  basin  is  already  hard  and  unusable. 

So  that,  in  this  particular  case,  I  recommend  you  to  use  bandages 
already  powdered. 

To  produce  good  ones,  you  will  take  tlie  following  two   precautions; 


rrvsTEHEn  srnii'S  I'nEi'Anri)  hefoui-ham).  :>.' 

1"  The  strips  will  be  plaslcreil  (o  liie  proper  degree  —  noillier  loo  much  nor 
loo  lillle  —  by  incorporating  60  to  70  grammes  of  plaster  lo  each 

metre  of' muslin  (i5  cm  in  widlli)  :  altogether,    3oo  grammes  oi'  plaster   lo 
the  entire  bandage  of  five  metres. 

Thus,  you  will  divide  your  pile  of  3oo  grammes  into  five  small  iicajjs  and 
use  one  of  the  small  heaps  witii  each  metre  of  slrip.  The  sprinkling  of  the 
strip  is  very  easy  :  you  do  just  as  in  preparing  a  whillug  (or  frviiig. 


l-^lo  II.  —  The  sprinkled  btrip  is  dipped  into  a  basin  of  water;  some  bubbles  of  gas 
are  at  once  disengaged  :  and  when  no  more  gas  comes  off,  it  is  ready  for  use ;  take 
it  out,  press  it,  and  apply  it. 

2.  So  as  not  leave  the  strips  to  decompose,  preserve  them  in  a  tightly 
closed  receptacle  until  you  use  Ihem,  or  better  still,  do  not  sprinkk'  tiiem  until 
a  Utile  while  (1/4  to  1/2  an  hoan  before  you  prepare  your  a^jparatus. 

When  you  wish  to  construct  the  apparatus,  dip  two  of  these  strips  into 
a  basin  of  water,  so  that  each  of  Ihem  is  entirely  immersed  (v.  fig.  ii); 
leave  them  soaking  until  you  no  longer  see  bubbles  of  air  on  the  surface  of 
Ihe  water  (about  a  or  3  minutcsj  :  at  that  moment,  take  the  first  strip, 
squeeze  it  thorouglilv  and  wring  it,  holding  it  by  the  two  ends  (v.  fig.  12) 
and  set  about  applving  it. 

As  tliestrips  should  not  be  left  toolongin  the  water,  because  they  nouldhar- 
den  and  become  useless,  care  must  be  taken  thai,  Adhere  a  large  number  of  strips 
are  being  used,  —  as  is  obviously  the  case  in  making  a  plasler  corset  for  an 
adult,  —  they  arc  not  all  put  in  the  water  to  soak  at  the  same  time,  but  dip- 


28 


TECIOIQUE    OF    PLASTER    APPARATUS 


ped  in  successively,  at  intervals  as  nearly  as  possible  equal  to  the  time  taken 
in  applying  one  strip  to  the  patient. 

Then,  the  first  strip  having  been  applied,  and  before  removing  the  second 
from  the  basin,  you  place  a  third  to  soak;  befcjre  applying  the  third  you  dip 
a  fourth,  arid  so  on. 

As  to  the  plastering  of  the  attelles  (^vhen  the  strips  have  been  prepared 


Fis;.   13.  — •  Tlie  best  method  of  hokling  and  squeezing  the  wet  plastered  strip. 

by  the  second  method  of  previously  sprinkling)  is   should  always  be  done  in 
the  aboved  described  manner,  soaking  the  attelles  in  the  cream. 


F. 


APPLICATION  OF  THE  PLASTERED   STRIPS   AND  ATTELLES 


Immediately  they  have  been  plastered,  as  we  have  said, 
the  strips  and  attelles  should  be  applied  without  any  delay, 
for  the  cream  prepared  in  the  proportions  indicated  above 
(5  parts  of  plaster  to  3  of  water)  begins  to  "  set  "  in  about  ten 
minutes. 


Tin:    WAV    Ol       \ll'I.MN(i    THE    I'LASTEUED    STKII'S 


^D 


The  strips  and  allcllcs  must  be  applied  in  less  than  ten 
minutes  in  oidcr  llial  there  remains,  at  the  very  least,  two  or 
ihrce  minutes  before  the  setting  of  the  plaster,  to  correct  the  posi- 
tion of  the  limb  and  to  elTect  any  '*  modelling  "'. 

But  let  me  assure  you  that  you  Avill  ahvavs  find  it  easy,  in  llie  case  of  a  leg 
apparatus,   to  be  in  time.       ^ou   Avill  have  to   allo\\    pretty    nearly   for   each 


First  strip  :   begin  at  the  extremitv  of  the  foot,  at 

Apply  without  tightening  ;  spread  out  the  strij 


le  base  of  llie  toes. 


stage  :  a)  for  applying  the  strips  :  one  to  two  and  a  half  minutes  at  the  most; 
b)  for  applying  the  attelles,  about  as  much.  Altogether,  five  or  six  minutes 
at  the  most  :  there  are  then  fully  five  minutes  more  ^^vhich  is  more  than  you 
need)  to  correct  the  position  and  effect  the  modelling'. 


I.  But  if  it  is  very  easy  to  finish  in  good  time  in  preparing  a  leg  appara- 
tus, it  is  much  less  easy  to  do  so  in  preparing  a  large  apparatus,  lor  Pott's 
disease,  or  even  for  coxitis,  when  one  is  "  out  of  practice  ".  Consequently 
for  these  large  apparatus  you  should  prepare  a  thinner  cream  (to  5  parts 
of  plaster  put  4  parts  of  water  instead  of  three)  that  will  give  you  five  minutes 
more  margin,  that  is  to  sav  the  setting  of  this  cream  will  take  about  fifteen 
minutes.       But  we  >Aill  return  to  this,  a  propos  of  the  plaster  corset. 


3o 


THE    STRIPS    MUST    BE    APPLIED 


SPREAD    OUT ; 


a.   The  application  of  the  strips. 

Take  a  plastered  strip,  —  Avltliout  squeezing  it,  or  scarcely 
at  all  —  and  applv  it  l)y  commencinfj'  at  the  extremity  of  the 
toes. 

Mode  of  application  of  the  strips.  —  One  makes  circular 
turns  Avhich  overlap  a  half  or  third,  but  one  never"  reverses  ". 
That  is  not  necessary  ^^itll  bandages  which  are  soft  and  moist  : 
they  mould  themselves  to  the  contours  of  the  limb  and  fold 


Yis-   li-   —  How  not  lo  do  it.     Do  not  let  the  bandage  make  creases  upon  the  instep 
as  it  is  doins  here. 


themselves  lightly  where  it  is  necessary  Avithout  those  folds 
causing  wounds,  for  they  are  very  small  and  even  smaller  than 
those  vou  \\ould  make  ^^ith  reverses. 

These  circular  turns  overlapping  one  another  thus  cover  the 
fool,  the  instep,  the  leg,  the  knee,  and  ascend  up  to  the  lower 
third  of  the  thigh. 

The  topmost  turn  of  the  plastered  strip  should  cease  i  cm. 
below  the  upper  border  of  the  jersey. 


2'*     EXACILY,     O"     WITIIOI  T    THVCTION     OH     l'lti;SSI  UK  At 

Three  recommendations  as  lo  llic  mamiei-  ol  appi  viiifr  llic 
strip;  spread  ll  oiil  :  appl\   il   exactly  bul  without  traction. 

I.  The  sprcu'liii'/  Old  :  avuid  niakini^  l\\i>ls.  Iml  willioul 
l)L'iny'  in  the  nicaiilime  concerned  about  the  ine\itahlc  (and 
nciiliyeahlc)  small  folds  occurring  in  the  strip  rolled  rr)und  a 
region  not  regularly  cylindrical  (lig.  i4).  Rather  than  make  a 
"  lAvlst  "  cut  your  strip  and  spread  out  the  ends.     If  care  be 


Fig.  ij.   —  The  creases  which  the  slrip  mav  make  are   effaced  by  tlie   left   hand  a^ 
soon  as  they  are  made. 

taken  to  spread  out   the  strip  the  apparatus  ^^ill  not  cause  any 
Avound. 

2.  To  apply  the  plastered  strip  exactly,  folloAv  carefully 
the  contours  of  the  region.  You  can  flatten  out  Avilh  the  left 
hand,  as  you  go  on,  each  turn  applied  hy  the  right  hand 
(v.  fig.  1 5).  And  in  this  way  you  will  have  a  well  fitting 
apparatus,  neither  loose,  nor  slack. 

3.  Do  not  lighten  (a  mistake  often  made  by  beginners). 
Avoid  causing  cedema  of  the  limb  (v.  fig.   i6)  :  make  no  Irac- 


32 


TECHMOUE    OF    PLASTER    APPAllAXUS 


tion,  no  pressure.  Take  care  not  to  pull  on  the  strip,  as  you 
would  on  an  Esmarch's  bandage.  Apply  the  strip  as  if  you  had 
to  take  an  impression  of  the  contour  and  the  volume  of  the 
limb,  without  adding  or  curtailing  anything,  and  in  this  way 
you  will  have  plasters  which  Avill  cause  no  discomfort. 

The  first  covering  having  been  finished,  when  with  the  ban- 


Yicr,   i(j,  —  What  YOU  sliottld  avoid.      Do  not  pull  on  the  strip  for,  in  pulling,  the  limb 
is  constricted  as  is  sho>vn   liere. 

dage  you  have  arrived  at  the  upper  border  of  the  apparatus,  if 
the  strip  is  not  used  up,  you  Avill  tear  it  Avith  your  hands,  or 
better,  cut  it  with  scissors,  and  keep  the  remainder  to  apply  later 
on  over  the  attelles. 


6.  The  application  of  the  Attelles.  0\er  the  first  covering 
made  with  the  strips,  the  two  attelles  are  applied  (fig.  17,  18 
&  19).  You  take  one  of  them,  it  does  not  matter  Avhich  (they 
are  equal);  squeeze  it  slightly ;  spread  it  out  and  apply  the  first 
one  behind.  Spread  out  one  of  it's  extremities,  first  under  the 
toes  where  the  assistant  lakes  hold  of  it  and  keeps  it  in  position, 


THE    APPT.ICATIOX    0\-     TIIK     VT'IEI.LES 


33 


llicn  aloiiL;  llic  sulc  aiul  upwards  under  ihe  heel,  -svliirli  j| 
encl<>ses  allerwards,  osor  llic  whole  ol'  ihe  poslerior  part  ol  ijie 
Yimh,  under  ihe  hack  of  llic  knee  as  far  as  the  upper  border  ol' 
the  apparatus  A\hercil's  cxlrcmilx  is  held  hy  someone,  or  l)\  llir 
pilient  linnself. 


Fis.  I- 


Posterior  attelle  :  Legin   it's  application  under  the  sole  of  [he  foot. 


The  other  attelle  —  anterior  attelle  — is  applied  in  fronl. 


begining  also  at  the  toes'. 


1 .  If  YOU  wish  to  protect  tlie  toes  from  tlie  pressure  of  the  bedclothes  you 
may  alloAA-  the  lower  end  of  the  attelles  to  project  hvo  or  three  centimetres 
beyond  them.  If  by  doing  so  vour  attelle  is"  too  short  at  the  upper  part,  it 
is  of  no  consecpience  :  you  will  only  have  to  strengthen,  by  some  supplemen- 
tary strips,  this  part  of  the  apparatus,  where  the  allelic  is  wanting. 

2.  But  without  going  further,  without  going  even  as  far  as  their  extre- 
mity, one  leaves  bare  the  last  joint,  in  such  a  Avay  as  to  allow  of  constant 
inspection  of  the  skin.  You  could  also  take  no  notice  of  this  recommen- 
dation during  the  construction  of  the  plaster,  and  cover,  without  hesitation, 
the  dorsal  aspect  of  the  toes,  provided  that  you  liborale  it  when  you  trim  tlic 
plaster. 

C\LOT.   —  Indispen-able  orthopedics.  3 


34 


TECm'IQUE    OF    PLASTER    APPARATUS 


You  carry  out  the  application  of  the  attelles.  at  the  same  lime 
spreading  out  and  smoothing  down  their  edges  in  such  a  manner  as 
to  avoid  any  sharp  projection,  Avhich  is  very  easy  Avilh  attelles 
so  thin  as  tliese  (made,  as  I  said,  Avilh  one  or  tAvo  sheets  of 
muslin). 

The  edges  of  the  allelles  Avill  overlap  each  other  at  the  level 
of  the  narroAv  parts  of  the  region,  Avhich  is  an  advantage. 


Fjo-.   18.  —  The  application  of  the  posterior  atlelle  (continued).      "While  the   assistant 
keeps  in  place  the  plaster  portion,  you  spread  out  the  middle  portion  under  the  calf. 

To  facilitate  and  perfect  their  imhricalion  you  may  incise 
the  edges  Avith  a  cut  of  the  scissors  at  the  level  of  the  malleoli 
and  the  heel. 

Over  the  attelles  a  covering  is  made  Avith  plastered  strips  : 

one  uses  one  or  two  strips  (according  as  one  is  dealing  Avifh  a 

child  or  an  adult).      The  strips  are  rolled  from  toe  to  thigh,  and 

then  from  thigh  to  toe  —  until  the  strips  are  used  up. 

An  important  detail. 

BetAveen   the  different  layers   of  the  apparatus  you    spread 


sriiiM)   ii.vsri'H  (;ui;\M    liicTAvicr.N    run  i.wkus 


35 


N\illi  \niii-  liaiiil  ,1  l;i\ci'  (iiii"  (ir  Iwn  millimolics  lliick  of  plaster 
cream  :  Mm  uso,  lor  llial  [)inp(ise,  wlial  remains  of  ihe  cream 
aller  llif  plaslerlni^-  ol'  llie  ships  and  allcllcs;  or  if  none  of  il 
remain,  von  al  once  prepare  a  new   siij)|)lv. 

Tliis  laxer  of  plaster  cream  is  llie  mortar  '  which  hinds  into 
a  sini^le  liomoi^cncons  l)locl\  llic  difTeienI  pails  ol  llie  appaialiis. 


Fig.  19.  —  The  posterior  attelle  applied.      It  encloses  half  tlie   circumfcreace  of  Ihe 
posterior  aspect  of  the  limb,  after  the  fashion  of  a  casing. 

Then,  over  the  last  strip,  spread  a  final  layer  of  cream,  to 
give  a  fmishing-  touch-  to  the  apparatus. 
It  is  now  complete. 


The  application  of  the  strips  and  attelles  should  occupy 
from  three  to  four  minutes,  not  more  than  five. 

1.  Witliout  this  mortar  one  runs  tlie  risk  of  having  the  plaster  not  homo- 
geneous (a  "  gateau  feuillete  ")  especially  if  it  has  been  jirepared  with  strips 
dusted  beforehand  ^a  ith  plaster. 

2.  V^  e  will  explain  further  on,  p.  79,  the  methed  of  polishing  the  appa- 
ratus. 


36 


TECIIMQUE    OF    PLASTER    APPARATUS 


You  Avill  have  then  before  the  selling  of  the  plaster, 
several  minutes  Avhich  are  necessary  for  correcting  the  position 
and  moulding  the  apparatus. 

((  Several  minutes  o,  that  is  the  desired  margin;  not  too 
much  nor  too  little.      \ou  should  have  calculated  evervthing  so 


Fisf.   20.   —  The  anterior  attelle  is   then  placeJ  in  posilicn. 

that  this  may  be  so;  that  is  to  say,  you  should  not  only  have 
tesled  your  plaster  beforehand,  but  more  than  that,  if  you  are  a 
novice  vou  should  have  made  a  rehearsal  and  constructed  a 
plaster  on  the  same  plan  upon  a  living  model. 

But  Avould  it  not  be  possible,  Avhen  you  have  not  settled 
on  vour  plan  and  taken  the  necessary  precautions,  to  advance 
or  retard  slightly  the  setting  on  the  plasterP 

To  hasten  the  setting  it  is  recommended  in  some  books, 
to  drv  the  surface  of  the  apparatus  ^^itll  hot  napkins,  or  Avith 
several   turns   of  drv   linen   banda<aes   Avliich   vou   lake   off  in  a 


I.  bee,  p.  2g. 


NEiuiv    riii:   rosiTioN  87 

lilllc  wliilc.  nr  1(1  powdrr  llic  (laiiij)  surlacc  of  tlic  ;i|)ji;ir;iliis 
wilh  a  la\<M-  of  (uic  lo  Iwn  iiiillinictrcs  of  tlrv  plaster,  oi", 
better  slill,   lo  la\   on   Ixilli  aspccls  nf  ihc  appaiadis  two  pieces 

of  dry  m\i-;lin. 

But,  I  advise  vou    l<i   do    iinlhini^    of  llic    kind,  and  not  lo 

use  any  of  lliesc  means,  Avhicli  spoil  the  plaster;  use  simply... 

a  little  patience:  and  so,  the  setting  not  having  been  ((forced)), 

the  plaster   should   be    firmer,   more  homogeneous  and    more 

presentable. 

As  to  the  methods  of  retarding  the  setting,  all  those  which 

have  been  proposed  are  uncertain  or  even  objectionable  ;  ihoy 

aggravate  mailers  instead   of    improving    them    and    tend    to 

((  turn  »  the  plaster. 

No,    if    the    plaster    appears  disposed  lo    dry   a    little    too 

quickly,  the  only  thing  to  be  done  is  lo  out-do  it  in  quickness 

and   lo    roll    the  last   layer    of  bandage    so   as    to    hasten    the 

modellinsf'. 

G.    —   VERIFICATION  OF  POSITION   AND  MODELLING 

a.  Verification  of  Position.  —  Verify  and  rectify  if 
need  be,  the  position  of  the  asssistant  who  holds  the  foot ;  and 
even  lake  his  place  in  this  delicate  role,  if  you  are  not  sure  of 
him  and  put  him  in  yours  to  perform  the  modelling,  Avhich 
is  assuredly  more  easy  than  putting  in  good  position  the  foot 
and  the  leg. 

If  you  have  to  pull  on  tlie  leg.  change  noAv  and  then  the 
position  of  your  hands  so  as  not  to  exercise  a  continuous  pres- 
sure on  the  same  point,  which  might  cause  an  abnormal  pro- 
jection of  the  plaster  within,  at  this  point. 

I.  Once  again,  you  A\ill  avoiil  all  these  annoyances  by  testing  your  plaster 
beforelian(i.  And  if,  in  spite  of  everytliing  you  fail  in  your  apparatus,  if  for 
example  you  find  the  first  layer  set  before  liaving  applied  the  last  strip,  well ! 
you  will  at  once  have  to  take  off  the  apparatus  —  which  is  easy  —  and  begin 
again.  That  has  happened  to  us  many  times,  and  we  do  not  consider  it  any 
discredit.  ^ou  liave  alwavs  the  resource,  to  save  vour  reputation,  of  attri- 
buting the  premature  setting  to  an  over  baking  of  the  plaster. 


38 


MODELLING    THE    PLASTER 


b.  Modelling  the  Plaster.  —  The  plaster  is  modelled 
by  impressing  it  around  the  osseous  prominences  {not  upon 
them,  which  might  produce  sloughing ,  but  around)  in  such  a  way 
as  to  accommodate  the  prominences  in  depressions  of  the  plaster. 
Here,  at  the  knee,  the  modelling  is  done  by  enclosing  the 
region  with  both  hands,  like  two  spherical  covers ;  the  plaster 
should  mould  itself  over  the  patella   and  the  condyles.      Press 


Fig.  21. 


Modelling  of  the  apparatus  around  the  patella  and  heel. 


it  into  the  groves  which  lie  between  the  patella  and  the  condyles. 
In  pressing  it  one  suppresses  the  bridges  which  it   makes  at 
these  points ;    one   prevents  in  this  way  the   knee   and  the  leg 
turning  in  the  apparatus. 

In  a  Avord,  one  utihses  all  the  protruding  parts  (condyles, 
patella,  tuberosities  of  the  tibia)  of  the  knee  joint,  which  form 
so  many  keys  betAveen  the  leg  and  the  plaster  envelope.  That 
is  to  say,  one  models  the  plaster  in  this  Avay  above  and  below 
the  knee,  around  the  femoral  condyles  and  the  tibial  tubero- 
sities.     One  is  able  also,  to  slightly  model  the  malleoli  and  the 


Mdiii  ii.iM.    riii:    i>i,\sii;u 


•^!) 


aivli  of  Mil'  liHil.  lull  ihis  is  piaclicill  \  useless  :  in  arn  case, 
IIm'  iiHulilliiiL:  will  lM'c,i>il\  clleclcd  ■\\  illi  lliclwo  liarids  wlilcli 
j^iasp  (lie  looi  and  llio  mallei  )lar  rc;^ioii.  Ymi  sin  mid  preserve 
ihc  correction  and  llie  modelling  right  up  to  the  setting  of 
the  plaster,  inclusively;  il  is  somelimcs  rallier  tr\iii^-,  bul  il 
is  absolutely   indispensable,   if  you  A\isli    to   lose   none  of    tin' 


Fig.  22.  —  AVlien  the  plaster  is  set  you  raise  tlie  lieel  so  that  tlie  air  passing  bencalli 
tlie  apparatus  assists  the  dryinj;  (do  not  confound  the  setlirifj  o(  tlie  plaster,  which 
requires  several  minutes,  with  the  drjinr/,  which  requires  several  hours  and  even 
sometimes  several  days).  . 

correction  obtained.  One  recognises  that  the  plaster  is  set  by 
it  no  longer  creasing  on  the  surface ;  by  it  emitting  a  sound 
under  the  finger,  when  tapped;  by  it  being  warm,  remembe- 
ring hoAvever  that  Avhen  it  has  been  prepared  with  cold  water, 
itAvillnot  always  be  warm  to  an  appreciable  extent,  even  when  the 
plaster  is  good.  AVhen  the  plaster  is  set,  and  then  only,  you 
may  release  the  patient's  foot  and  place  it  on  the  table,  or 
better  still,  on  the  back  of  a  cliair,  to  hasten  the  drying  of  the 
plaster. 


l\o 


TRIMMING    THE    PLASTER 


II.    —  TRIMMING  THE  PLASTER 

Ten  or  fifteen  minutes  after  the  plaster  is  set,  you  may 
commence  trimming  it  with  a  good  knife,  cutting  gently  and 
slowly  upon  the  apparatus,  aa  hich  at  this  moment,  permits  of 
being  cut  like  soft  card-board;  you  cut  off  the  part  which 
covers  the  extremities  of  the  toes,   in  such  a  way,  as  to  expose 


Fig.  23.  —  Trimming  the  plaster  by  means  of  a  knife  or  bisloury. 

the  dorsal  aspect  of  the  last  phalanx.  One  takes  care  not  to 
cut  into  the  jersey  or  stocking,  in  order  to  preserve  a  surplus 
of  the  covering  Avhich  Avill  prevent  the  friction  of  the  plaster 
over  the  bare  skin.  One  frees,  in  the  same  Avay,  the  upper 
part  of  the  apparatus,  preserving,  here  again,  2  or  3  cm.  of 
the  soft  casing  beyond  the  border  of  the  plaster. 

Thanks  to  this  trimming  of  the  loAver  extremity  of  the 
plaster,  one  is  able  to  make  an  easy  and  continuous  inspection 
of  the  nutrition  of  the  toes.  (If  all  be  weU  with  them,  one  is 
assured  of  the  good  nutrition  of  the  foot  and  of  the  leg). 


MAki;   SI  Ki:  Of    riii:   MriuiiDN   oi'    iiir,  i.niis 


'|i 


The  Iocs  oii'^'lil  lo  be  sensitive  lo  llie  [)ricls.  of  a  [)in.  rosy, 
Avarin.  ami  supple. 

Voii  imisl  always  look  at  them  before  lea\irig  the  house  and 
it  will  be  sufficient  afteiAvards  if  someone  of  the  family  Avatches 


Fig.  24.  —  The  apparatus  complete,  trimmed  and  polislied. 


them  every  hour  for  the  first  day,  then  morning  and  evening  on 
the  following  days,  drawing  a  pin  over  the  surface  of  the  toes  \ 

I.  Anyone  may  easily  perceive  the  least  trouliles  or  anomalies  of  tliis 
kind ;  it  AA'ill  be  sufficient  for  him  to  compare  the  results  of  examination  of 
the  affected  side  with  that  of  the  sound  side;  moreover,  in  case  of  doubt,  this 
person  should  advise  you  immediately,  and  in  this  way,  if  any  trouble  ^^  liat- 
ever  should  happen,  even  unexpectedly,  during  the  folloAvingdays,  you  would 
alwavs  be  able  to  remedv  it  in  time. 


42  TECIIMQUE    OF    PLASTER    APPARATUS 

If  the  patient  is  unable  to  move  them  voluntarily  you 
should  open  the  plaster  by  a  median  slit  from  top  to  bottom, 
until  they  do  move. 

You  split  the  plaster  first  on  the  middle  of  the  dorsal 
aspect  of  the  foot,  afterwards  on  the  anterior  aspect  of  the 
instep,  and  Avith  a  spatula,  or  even  Avith  the  hands,  you  Aviden, 
for  one  or  tAvo  centimetres,  the  still  soft  edges  of  the  plaster, 
stopping  the  instant  that  the  normal  sensibility  and  colour  of 
the  toes  return. 

If  these  do  not  return,  you  Aviden  more  and  split  the 
plaster,  further  and  further  upAAards,  if  need  be  up  to  the  upper 
border,  and  raise  the  edges.  Then,  everything  should  return 
to  the  normal. 

You  have  only  then  to  fix  the  plaster  at  this  degree  of 
AA'idening  Avith  a  plastered  strip,  or  a  simple  muslin  bandage. 
In  short,  provided  that  you  ncA-er  depart  from  this  absolute 
rule  of  never  leaving  your  patient  Avithout  haAing  positi- 
vely ascertained  that  the  toes  (or  the  lingers)  are  rosy,  warm 
and  sensitive,  I  can  guarantee  that  you  Avill  never  have 
serious  trouble  Avith  nutrition  after  the  application  of  a  plaster, 
be  it  the  loAAer  limb,  or  the  upper  limb. 

After  the  trimming,  the  patient  is  carried  to  his  bed. 

The  Method  of  lifting  and  conveying  a  plastered  subject, 
so  as  not  to   injure  the  apparatus. 

Take  hold  of  the  leg  in  such  a  manner  as  not  to  make 
any  movement  contrary  to  the  position  given,  or  Avhich  tends 
to  call  into  play  the  articulations  fixed  by  the  apparatus.  One 
leaves  the  plastered  leg  exposed,  the  heel  raised  so  that  the  drying 
of  the  plaster  may  proceed  as  Avell  beloAv  as  aboA^e  (v.  fig.  22). 

Do  not  confuse  this  drying  Avith  the  setting;  the  latter 
does  not  require  more  than  ten  minutes,  Avliile  the  former 
requires  one  or  tAvo  days,  sometimes  more ;  during  that  time, 
one  should  guard  against  moving  the  patient,   for  the  plaster, 


AFTEft    CAIU: 


^3 


so  loiiy  as  I  lie  Irasl  iiii)isliuc  icuiaiiis,  is  likcl\  lu  break; 
however,  if  il  A\ere  lo  break,  il  A\oiild  be  quite  easy  to  repair 
if  ;  AVC  Avill  ilcscrilie   liow   in  a  niDmcnt. 


Attentions  to  be  paid  after  application   of  the  plaster 

The  plaster  bein,a'  construcled,  vour  iniinedialc  laljours  arc 
ended.      The  patient  beinii'  returned  to  bed,  a   hot  water  ])oltlc 


Fig.  20.  —  If  tbe  small  toe  is  too  much  pressed  upon,  you  free  it  l^y  making  small 
slits  along  the  external  border  of  the  foot  (one  frees  the  internal  border  of  the  foot 
in  the  sEime  way  if  the  great  toe  be  too  much  pressed  upon). 

may  be  placed  on  each  side  of  the  plaster  to  hasten  its  drying. 
The  toes  must  be  protected  against  the  pressure  of  the  bed- 
clothes, thus  facilitating  the  circulation  of  air  round  the  appa- 
ratus, and  helping  the  drying.  It  is  Avell  for  this  purpose,  lo 
leave  the  plastered  region  outside  the  bedclothes,  for  the  first 
twenty-four  hours. 

A  plaster  ought  not  to  cause  any  more  discomfort  than  a 
well  made  boot. 

At  the   most,  the   patient  may  complain  of  a  sensation  of 


kk 


TECHNIQUE    OF    PLASTER    APPARATUS 


uneasiness,  similar  to  that  caused  by  a  ne\Y  boot.  If  you  call 
on  your  patient  a  fe^Y  hours  afterwards,  or  the  next  day,  he 
will  tell  you  perhaps  that  he  feels  some  uneasiness  at  the  edges 
of  the  apparatus;  the  two  outer  toes,  the  great  and  the  small, 
may  be  a  little  pressed  upon  by  the  plaster.  In  that  case, 
introduce  a   spatida  between   the  toes  and  the  apparatus,  and 


Fig.  26.  —  A  bi'oken  apparatus,  which  must  be  repaired  and  strengthened. 

try  to  widen  it  by  a  few  millimetres.  If  that  is  not  sufficient, 
split  the  plaster  a  little;  do  not  clip  it  transversely;  no,  cut 
longitudinally  the  inner  or  outer  side  (as  the  case  may  be), 
for  a  length  of  one,  two,  or  three  centimetres,  beginning  at 
the  free  edge;  afterwards  Aviden  slightly  the  two  lips  of  the 
gap,  in  order  to  give  the  toe  a  little  more  liberty  (fig.  20). 

And  the  same  in  the  thigh,  if  the  upper  edge  of  the  plaster 
presses  into  the  soft  parts,  commence  by  sliding  under  the  edge 
a  slender  and  even  pad  of  cotton  avooI,  and  if,  in  spite  of  that, 
the  patient  still  complains,    split  the  apparatus  for   the  length 


iiiiw     I'o   mutm;  I  iii:\    iiii.   n.vsrr.H 


^i5 


(i|    a    few    ceiiliiiii'lrt's.    widrii    (lie    li|).s   oC    llir    y:;\p    made,   and 
inlnnlucc  a  laM'ior  colldii  \\ool  lu  prolccl  ihe  skin  IVoni  injury. 

A\  ('  will  now  dt'sciibc   : 

a.  The  melliod  of  strengthening  llie  piaster; 

6.  The  manner  of  repairing  il ; 

<■.  The  niclliod  of  making  openings  into  it; 


Fig.  27  —  How  to  repair  a  plaster.  —  After  having  slightly  moistened  the  region 
with  very  lliin  cream,  yon  apply  a  large  square  of  muslin,  of  one  thickness  only, 
impregnated  with  the  cream,  then  a  second,  then  a  third. 

d.  The  method  of  removing    it   and  performing-   (he  toilet 
of  the  limb. 


a.  How  to  strengthen  the  plaster. 

If  the  phister  seems  too  slender,  whether  it  he  some  minutes, 
some  hours  or  some  days  afterwards.  }ou  strengthen  it  in  tlic 
folio\Aing  manner. 

It  is  the  whole  of  the  apparatus  which  needs  to  be  streng- 
thened,     ^ou  commence  by  applying-  over  the  whole  surface  a 


46 


IIOAY    TO    REPAIll    A    LROXEN    PLASTER 


layer  of  thin  plaster  cream  (equal  parts  of  water  and  plaster), 
then,  over  this,  you  spread  two  attelles  (of  a  single  layer  of 
muslin),  one  of  the  attelles  in  front,  the  other  hehind,  then  a 
third,  and  a  fourth  (always  of  one  thickness  only) ;  and  over 
all  you  roll  one  or  two  plastered  strips.  If  it  is  only  at  one 
or  two  points    that  the  plaster  is   weak   you  apply,  at  these 


Fig.    28.  — Over  tlia  squares,  several  lavers  of  pki~terci-l  strips  are  applied. 

points,  going  heyond  the  limits  of  the  Aveak  portion,  a  similar 
layer  of  plaster  paste,  then  several  squares  of  muslin  (fig.  27), 
lastly,  2  or  3  turns  of  plastered  strips  (fig.  28). 

b.     How  to  repair  the  plaster. 

And  when  the  plaster  is  cracked,  or  hroken  completely 
(fissure  or  fracture)  a  long  or  short  time  after  its  construction, 
it  is  not  generally  necessary  to  replace  it;  one  may  very  well 
repair  it  and  make  it  sound  again  (fig.  27,  28)  proceeding  in 
pretty  nearly  tlie  same  Avay  as  in  strengthening  it. 

First  of  all  remove  the  debris  of  plaster  which  borders  on 
the  crack,  then  roughen  the  surface  Avith  a  knife;  you  hollow 


IKiW      II)    CLEANSE    A    Sf)lLi:i)    I'l.ASTEK 


^•7 


out  Utile  depressions  wilh  llic  point,  as  yju  piick  the  ice  wilh 
\our  alpensloclv  to  oljlain  a  grip;  you  (lam[)  arierwards  llic 
irregular  and  jagged sur^ace^villl  some  lliiii  plaster  (equal  parts 
of  plaster  and  ^\ater). 

AA  hen   llic  jilasler   is   soiled,   its  A\Iiitcness   can    ho   retimed 


Fig.  29.  —  How  lo  make  an  opening  in  Ihe  plaster.  —  The  piere  to  be  removed 
is  first  marked  out.  then  cut  with  a  knife,  going  through  the  wliole  thickness  of 
the  plaster;  this  piece  is  lifted  out  by  one  corner  and  removed  a'.losether. 

by  the  application  of  a  film  of  paste  made  wilh  these  same 
proportions  of  plaster  and  water. 

\A  hen  it  is  softened  by  urine  or  by  pus,  the  soiled  part  is 
cut  out  and  replaced  by  squares  or  attelles  held  in  position  by 
a  few  turns  of  plastered  strips. 

Do  not  use  thick  paste  or  attelles  of  several  thicknesses; 
this  is  the  secret  of  success  in  these  immediate  (or  late)  repa- 
rations, Avhicli  pass  as  difficult.  If  the  paste  or  the  attelles  are 
too  thick  the  ne^A  pieces  will  not  incorporate  with  the  old 
plaster,  A\hereas  in  ihe  method  I  have  just  described,  the  union 


/.8 


TECHNIQUE  OF  PLASTER  APPARATUS 


is  very  intimate  and  very  firm,   and  yoit  will  be  as   expert  in 
repairing   the  "  old  "  as  in  making  the  "  ne^\  ". 

c.     How  to  make  an  opening  in  the  plaster. 

To   make  an  opening  in  the  plaster,  as  in  trimming,  you 
cut  layer  by  layer,  very  gently,  until  you  experience  a  sensation 


Fio-,  3o.  —  "When  the  piece    is  removed  one    cuts    the  jersey  diagonally    and    folds 
back  the  flaps  :  the  skin  is  laid  bare. 

ol  cutting  the  tissue   of  the  jersey,  and  no  longer  the  plaster. 

There  is  often  an  indication  for  the  making  of  an  opening: 

To  inspect  a  projecting  fragment  of  bone,  a  wound,  an  abcess, 
a  fistula,  etc. 

One  ought  to  note  these  different  points  and  protect  them 
by  a  double  square  of  gauze,  Avhen  constructing  the  plaster. 

Wait,  before  making  these  openings,  until  the  plaster  is 
dry  (at  least  2^  hours),  unless  however  it  be  a  matter  of 
urgency,  for  example  in  the  case  of  a  wound  suppurating  freely, 
which  should  be  dressed  the  same  day,  or  again,  that  of  a  bony 
projection  which  ought  to  be  put  back  as  soon  as  possible,  if 


iiMW     1(1    mam;    \n   ui'kmnc    iv    im:    i'|,\sti;k 


^0 


>0U  wish   to  save  ihc   alrea(l\    llirralcticd    >kiii  ;    in    (licso    rasos, 
make  the  opi'iiiiii;-  half  an   Ikhii-  aflei-  the  plaslci-  lias  sd. 

Jusl  as  in  liiniiniiiti',  (nic  makes  use  here  ol'  a  knife  well 
sitai-pened;  ciil  inillimelre  hv  niilliniclre,  unlil  Mm  come  upon 
llic  solt  llssuc  ol"  (lie  covering  which  nou  will  more  easih  sliL 
w  il  h   I  he  scissors. 


Fig.  3i.  — la   Ihe   case   of  a    wound   :  method   oi'  introducing    the   dressing   beneaht 
the  edges  of  the  opening. 

You  "will  not  Avoiind  the  skin  if  you  proceeed  cautiously. 
The  security  will  he  still  greater  il"  you  have  rememhered 
to  cover  the  skin  with  a  double  jersey;  it  is  then  that  you 
appreciate  the  value  of  this  precaution. 

Another  good  precaution,  when  you  know  beforehand  that 
you  may  have  to  make  an  opening  at  some  points,  is  to  place 
there  (over  the  jersey,  single  or  doubled),  a  little  square  of 
gauze  of  two  thicknesses,  or  some  fine  cotton  wool,  before 
applying  the  first  plastered  strip.  Thanks  to  this  square,  one  is 
able,  later  on.  to  make  an  opening-  in  the  plaster  at  this  point, 
without  the  fear  of  wounding  the  skin. 

Calot.  —   Indispen^:able  orthopedics.  4 


TECH^JIQUE    OF    PLASTER   APPARATUS 


Fig.  32.  —  The  flups  of  jersey  have  been  turned  do^n  over  Ihe  dressing. 

The  opening,  generally  square,  should  exceed  by  several  cen- 
timetres, in  all  directions,  the  point  to  he  watched  or  treated. 


Fig.     33.  —    The  dressing  is  retained  by  a  Yelpeau  bandage. 


now    TO   ur.Moxi:    iiii^  rLAsrcn 


01 


One  i-loscs  tlic  opcniiii^-  willi  an  ordinary  dressing  if  one  is 
dealing  willi  a  wonnd  (lig.  ,"ii).  or.  if  one  is  dealing  willi  a 
correction,  with  squares  ol  cmIIhii  wool  ki'[il  in  position  and 
well  llatlened  l)\  a  lew  lavers  ol"  stiU"  muslin,  moistened  and 
squeezed;   or  belter,  with  a  Yelpeaubandage  (fig.  32  and  .>3). 

D,  How  to  remove  the  plaster. 

The    time   having    arrived    for   the  removal   of  the  plaster* 


Fig.   3A.  —  How  to  remove  tlie  plaster.  —  The  lines  of  section. 
(The  plaster  has  been  previously  soltened  by  a  bath  or  by  >varm -wet  compresses.) 

it  is  split  in  front,  in  the  same  manner  and  Avith  the  same 
precautions,  as  I  indicated  foi-  trimming  and  making  an  opening, 
Avith  this  difference,  that  Avhen  the  plaster  has  just  been  cons- 
tructed it  alloAvs  of  being  cut  easily  (or  even  some  hours  or 
some  days  afterAvards) ;  whereas  when  some  weeks  or  months 
older,  it  does  not  allow  of  being  cut  without  some  difficulty. 
For  this  reason,  you  should  commence  by  softening  the 
old  plaster  on  a  level  with  the  line  which  the  knife  is  going 
to  follow.  You  damp  it  lo  or  i5  minutes  beforehand  Avith 
sponges    or  Avith  linen  soaked  in   hot  Avater.      This  facilitates 

I.  After  some  Aveeli.s,  or  may  Le  months,  according  as  it  is  a  fracture  or 
an  orthopedic  atrection. 


52  TECHXIOUE  OF  PLASTER  APPARATUS 

very  greatly  the  penetration  of  the  instrument,  and  Avhen  it  has 
cut  a  little  Avay  into  the  plaster,  you  keep  on  running  some 
hot  Avater  along  the  groove  ;  then  you  go  on,  in  this  Avay, 
damping  and  cutting,  right  doAvn  to  the  jersey;  then  you 
cut  the  jersey  Avith  the  scissors. 

But  this  method  of  removing  the  plaster  is  long  and  labo- 
rious ;    it  is    infinitely  more  simole  to  plunge  the  patient,  or  at 


Kig    35.  — How  to  cut  tlie  softened  plaster  h\  means  of  a  knife  :  you  raise  the  sides 
of  tlie  cleft  to  avoid   wounding  the   patient. 


least  the  plastered  limb,  into  a  hot  hath,  for  i5  or  20  minutes, 
whenever  this  is  possible,  that  is  to  say  nearly  ahvays.  As 
soon  as  the  patient  leaves  the  bath,  start  upon  the  plaster  Avith 
a  good  knife.  It  will  alloAv  of  cutting  as  easily  as  cardboard, 
and  the  section  and  removing  Avill  occupy  one  or  tAvo  mi- 
nutes (fig.   34  and  35). 

This  prehminary  softening  in  the  bath  afifords  a  still  greater 
security  :  the  edge  of  the  soft  plaster  alloAvs  of  it  being 
raised  sufficiently  by  means  of  the  fingers  for  you  to  be  able 
to  slip  easily  the  handle  of  a  spoon  betAveen  the  plaster  and 
the  skin,  and  you  can  then  cut  safely   upon    this   improvised 


iinw     Id   hi:m(i\i:    I  hi:  i'i,Asri:u 


:).{ 


guitlc  which  you  acl\aiice  hdle  \)\  hlll(;  towards  llic  olhfr 
extremity  of  the  apparatus. 

At  the  instep  one  is  often  tielayed  in  making  a  coniplcle 
section  by  abuttress  of  plaster  A\hich  corresponds  to  the  anj,do  ol' 
flexion  of  the  foot  (fig.  36).  But.  if  one  proceeds  with  cau- 
tion, one  can  divide  this  plaster  obslruction  without  scratching 
the  skin. 

As    soon  as  the  plaster   is   thus  cul    tlirough   from    lop    to 


Fig.  3G.   —  At  the   instep   there  nearly   always  exists  a  buttress  of  plaster  which    is 

awkward  to  cut. 

bottom  in  the  median  anterior  line,  one  separates  and  raises 
the  sides  and  so  can  remove  it  Avithout  difliculty.  At  the  instep, 
hoAvever,  I  Avould  advise  you  to  make  a  second  section  at  right 
angles  to  the  first,  before  raising  the  sides.  This  second 
transverse  section  is  ahvays  indispensable  Avhen  the  plaster  has 
not  been  softened  by  a  bath;  it  proves  very  advantageous  in 
any  case;  not  only  at  the  instep,  but  also  at  the  knee 
(v.  fig.  34). 


04 


HOW    TO    REMOVE    THE    PLASTER 


^A  hen  YOU  proceed  to  the  separation  of  the  sides  (especially 
Avhen  the  plaster  has  not  been  softened)  you  should  move  with 
prudence  and  method,  making  the  effort  symetrically  and 
ecpially,  on  the  two  valves  of  the  plaster.  Otherwise  one  tAvists 
the  limb  and,  in  the  case  of  a  debilitated  child,  or  one  in  whom 
the  skeleton  bv  disease  has  a   lessened  resistance',   there  is  a 


Fig,  87.  —  To  remove  the  plaster,  an  assis  ant   separates   the  sides  \\hile  you    raise 
the  limb  and  pull  upon  the  foot. 

risk,  by  such  torsion,  of  bending  or  even  fracturing  the  bone. 
A  good  precaution  is  to  confide  to  an  assistant  the  task  of 
pulling  very  firmly  on  the  foot,  whilst  you  proceed,  alone  or 
assisted,  with  the  raising  and  separating  of  the  two  valves  of 
the  apparatus. 

The  toilet  of  the  skin  after  removal  of  the  plaster 

If  one  need  not  replace  the  plaster  apparatus  again,  one   is 
free  to  make  the  toilet  of  the  skin  in  several   stages.      But,  if 

I.  For  example  in  tlic  case  of  a  congenilal  luxation  of  the  hip.  or  in  one 
of  tuberculosis  of  tlie  member. 


Tiir    loiiKi    (II    Till.   >-kiN    VI  rnu   UKxiowr,   oi-    rm:   i-i. vsir.ii      ,).) 

il  is  necessary  lo  re-[)last(r  llir  lliul).  (Uir  makes  llic  toilet  at 
once. 

One  nsos  for  this  warm  water  and  soap,  afterwards 
damping  sliglilly  the  skin  with  some  ether  or  Eau  dc  Cologne. 
If  the  skin  is  very  scaly  you  may  commence  hy  rubhing  the 
skin  gently,  (nv  a  few  minutes,  ^^ilh  vaseline,  anIiIcIi  has  the 
elTect  of  soi'leiiing  the  scales  of  epidermis;  you  wash  the  skin 
with  a  tampon  of  ordinary  cotton  wool  and  pour  over  it  a 
little  ether  or  alcohol.  Then  turn  the  patient  gently  over,  to 
make  the  toilet  on  the  other  side  of  the  limb. 

If,  as  is  most  unusual,  you  fmd,  after  removing  the  plas- 
ter, some  slight  alterations  in  the  skin,  eczema,  or  vesicles, 
you  will  attend  lo  these  carefully  for  a  few  days  before  repla- 
cing the  plaster,  by  applications  of  oxide  of  zinc,  or  talc  or, 
better  still,  hy  radiotherapy.  Failing  the  latter,  you  may 
leave  the  skin,  with  great  benefit,  without  any  dressing, 
lightly  covering  it  with  a  piece  of  gauze,  exposing  it  freely  to 
the  air  for  a  few  days,  or  heller  still,  to  the  sun  for  lo  mi- 
nutes the  first  day.  i5  the  second,  gradually  increasing  hy 
five  minutes  a  dav. 


II 

SUPPLEMENTARY  DETAILS^ 
ON  PLASTER  APPARATUS 


GOOD   AND    BAD   PLASTERS 

I  have  said  that  to  know  how  lo  construct  a  piaster  forms  part  of 
that  minimum  of  information  indispensable  to  all  practitioners  and 


Fig.  38.  —  A  bad  plaster. 

I.  Consult  that  excellent  book  of  my  assistant  in  Paris,  D''  Privat,  "  On 
plaster  apparatus  ". 


(;(Hii)   AM)   i;ai>   i'lasteks  7)- 

iirxcrllu'li'ss.  llicri-  arc  lew  |)r,K(ili()iiois  capal)!!'  ol'  luakiiiL;  a  i;oo(l 
plaslt-r  ;  not  llial  it  is  rcallv  cliriiciilt.  no!  Iml  il  i>  mil  lauirlil  in  oni- 
siliools.  Kor  that  icasoii  I  11111-1  explain  lo  \oii  licrc  in  di'lail,  I'lal 
wliuli  makes  ^0(h1  ami  liad  [ilaslcrs. 

Bad  plasters. 

I  mean  bv  bad  plasters',  plaslers  Avbich  arc  soft,  friable,  those 
apt  to  lose  tlicir  shape,  heavy,  ill  liltiiiir.  consccpieiillv  cpiite  inca- 
pable of  riiliiiliiii:  ihi'ii-  (lieia|)!'ii(ic  I'lmclion. 


Fig.  3(),  —  Another  bad  plaster.  —  These  I'.vo  figures  38  and  09  show  how  it  should 
not  be  done.  —  Here  are  two  plasters,  niu-jh  too  large  and  not  moulded  :  veritable 
floating  trowsers. —  One  easily  sees  that  a  plaster  made  in  this  way  (one  saddle  for 
all  horses  is  not  fitting  better  than  the  glass  case  over  the  clock  and  is  incapable 
of  thoroughly  maintaining  a  correction. 

These  plasters,  no  more  moulded,  to  the  bodv  than  a  sentry  box  to 
a  sentinel,  arc  nothing  more  than  cache-miseres  and  deceptions:  thev 
cover  but  do  not  support  ;  thev  hide  a  deformity,  but  thev  do  not 

I.  Are  die  plasters  of  all  "  specialists  "  reallv  beyond  reproach?  Ttiis  is 
like  asking  :  Do  all  surgeons  succeed  in  procuring  a  faultless  asepsis?  —  Do 
^\e  not  find  among  them,  some  who  Avork  bv  routine,  who  have  indilTercnt 
principles,  and  who,  alas  I  are  unnilling  to  depart  from  them.  But,  as  you 
know,  there  is  no  one  so  deaf  as  he  \\ho  A\ill  not  hear...     And  -till,  it  is  not 


58 


GOOD  PLASTERS  SUPPORT  AND  DO  NOT  INCONVENIENCE 


correct  it.     Moreover,  they  are  uncomfortable  or  painful  to  bear; 
they  fatigue  or  injure  — like  a  badly  made  boot  (fig.  38  and  Sg). 
And  yet,  it  is  absolutely  neces3ary  that  medical  men  should  know 


Fig.  /|0  and  4i.  —  Here  are  hvo  good  plasters  :  accurate,  well  moulded. 
Compare  them  with  the  bad  plasters  in  fig.  38  and  oij. 

how  to  make  good  plasters  ;  for  without  well  made  apparatus  there 
can  be  no  good  orthopedic  cures. 

Good  plasters. 

The  good  plaster  is  that  Avhich  supports  and  does  not  inconve- 
nience; those  are  its  two  essential  qualities;  if,  into  the  bargain  it 
is  elegant,  then  the  plaster  is  perfect  (fig.  4o  and  4i  )• 

more  necessary  to  be  a  professional  surgeon  in  order  to  he  aseptic  than  it  is 
necessary  to  be  a  specialist  in  order  to  make  good  plaster;  you  will  succeed 
completely  if  you  follow  the  technique  here  indicated. 


SUPE1U(IUI^^    nv  nii:  cihcli.au   i'i.vsiiu 


^9 


How  to  make  a  good  plaster  (well  lllliiiif.  coinroilaljlc  jurI 
neat)?  Fir-«;t  ol'  all,  il  >li()ul(l  \>r  a  circular  |ilastcr  (made  ^\itll 
strips)  ami  nol  a  plastered  gutter  ( luailc  willi  ihc  classical  sixlcca 
folds  ol"  nuislin). 

Tlio  superiority  ol  the  circular  plaster.  —  Il  is  bv  far  llic  most 
accurate  i>iiico  il  adajils  ilsdl  to  [\\c  (Ic^Jri^^Hnis  and  reliefs  ol  tlic 
^vllolc  surface  ol  llie  Ixxlvi;  it  is  llie  most  confortable  to  llic  [)alicnl 
(because  it  snpporU  him  iiiiil'oiinlv  cvorvw  licrc  i :  and   il    i<   the  most 


Fig.  !x2.  —  A  bivalve  apparatus  allowing  of  complete  examination  of  the  limb,  if  need 
be,  or  the  dressing  of  multiple  wounds  (The  two  valves  are  kept  in  contact  by 
means  of  a  sticking  plaster  bandage). 

simple  to  make  ( because,  to  mould  Avell  no  matter  in  \\liat  region. 
it  is  sufficient  to  roll  the  plastered  strips  after  the  fashion  of  an  ordi- 
nary muslin  bandage,  -whilst  it  is  impossible  to  mould  exactly  the 
plastered  «  gouttiere  »  made  up  of  i6  folds  of  muslin,  -without  ma- 
kinor  coarse  ridses  which  mav  wound  the  skin. 

But,  at  once,  you  ask  : 

a)  How  do  vou  inspect-  in  circular  plasters,  some  bad  or  suspected 
point  (a  fragment  of  projecting  bone,  a  wound,  an  abscess  or  a  fistula)  ? 
It  is  very  easy  :  simpiv  make  an  opening  at  that  point,  which  ope- 
ning will  not  lessen  the  support,  on  the  contrary,  as  we  use  it  (this 


I.  The  circular  plaster  is  the  best  for  the  limbs  as  weW  as  for  tlie  trunk, 
for  fractures  as  well  as  for  orthopedic  alTections. 


6o        HOW    TO    MAKE    A    PLASTER    WHICH    WILL    SUPPORT    WELL 

opening)  one  can  exert  more  pressure  on  a  certain  point ,  to  push  back 
a  bony  projection,  a  gibbosity. 

b)  How,  -with  a  circular  plaster,  can  you  make  a  complete  exami- 
nation of  a  limb,  if  necessary? 

First,  this  complete  examination  will  be  rarelv  indicated;  more- 
over, could  it  be  better  made  Avitli  a  plaster  goutticre?  And  besides, 
remember  that  this  examination  is,  in  reality,  possible  (and  even 
easy)  -with  a  circular  plaster,  seeng  that  it  is  sufficient  to  divide  the 
plaster  into  two  valves  which  you  can  take  off  and  reapply  as  you  wish. 

c)  Finally,  how  are  you  to  inspect  the  nutrition  of  the  limb,  in  a 
circular  apparatus? 

It  is  sufficient  to  ascertain  the  oood  condition  of  the  toes  and  fin- 
gers,  as  Ave  have  already  said. 

Any  alteration  in  their  colour,  warmth,  sensibility,  is  the  danger 
signal  which  allows  one  to  know  that  there  is  trouble  with  the  nu- 
trition higher  up,  and  to  do  at  once  what  is  necessary  to  remedy  it 
certainly ;  it  is  the  danger  signal  upon  which  you  can  always  rely. 

Besides,  these  troubles  of  nutrition  can  only  arise  from  some  fault 
in  the  construction  of  the  plaster,  or  from  the  breaking  of  one  of  the 
rules  I  have  given. 

But  do  not  believe  that  this  clanger  does  not  exist  Avith  gouttieres. 
It  does.  I  must  even  confess  that  tbe  only  really  serious  accident  Avhich 
I  have  CAcr  observed  to  be  caused  by  a  plaster,  occurred  20  years  ago, 
in  the  course  of  my  studies.  After  the  application  of  a  plaster  gout- 
tiere  to  a  fracture  of  the  leg  (of  an  alcoholic  subject,  it  is  true),  total 
gangrene  of  the  foot,  and  even  of  the  lower  part  of  the  leg,  occui'red 
beneath  a  sub-mallcolar  bracelet  of  diachylon. 

A.  —  HOW  TO  MAKE  A  PLASTER  WHICH  WILL  SUPPORT 
WELL? 

In  order  to  support  Avell,  a  plaster  should  fulfil  Iavo  conditions  : 
first  it,  should  be  sufficiently  long,  and,  secondly,  it  should  be  moul- 
ded to  the  region. 

a)  The  apparatus  should  be  sufficiently  long. 

It  is  necessary  that  the  plaster  should  embrace  not  only  the  part 
affected,  but  also  the  tAvo  adjacent  articulations  ^ 

I.  I  AA"as  asked  to  see,  in  a  large  foreign  capital,  a  patient  suffering  wi\h 
Pott's  disease  in  the  dorso-lumbar  region,  who  had  had  applied  a  plaster  belt, 
reaching  from  the  axilla  to  the  iliac  crest,  the  shoulders  and  the  pelvis  being 
entirely  free!  The  patient,  as  a"ou  may  well  believe,  moved  about  inside  it 
rather  like  Diogenes  in  his  tub.       And  still,  to  sj^eak  properly,  the  formula 


V^  coNDirioN  :  Tni:  plasteii  siioii.u  me  sufficiemi.y  l<»N(;     6i 

'l"liii<.  Id  coiiiplcli'l  \  iimiii)l)ili/i'  an  .illccle'il  krirc,  iho  .'ipparaliis 
sliould  iiicltulo.  at  llic  same  liino  as  tlic  knee,  the  hip  and  the  auklc. 

Ill  order  lo  hetler  iiniiiohili/e  the  inslep,  the  knee  and  the  entire 
fool  shoukl  he  include  d. 


Fig.  i3.  —  The  short  knee-piece  too  often  made  Much  too  short  and  loo  larire  :  llie 
tissues  are  allowed  to  be  depressed  by  the  edges  of  the  knee-piece  and  deviation  is 
produced  at  will. 

Fig.  4^4.  —  A  longer  knee-piece,  but  again  insufficient  for  the  same  reasons. 

Fig.  '|5.  —  The  perfect  method  of  immobilizing  a  knee.     Our  large  plaster  takes  in, 

not  only  the  knee,  but  also  the  two  adjacent  articulations. 

If  the  plaster  does  not  inchide  the  two  neighbouring  articvdations, 
a  deviation  within  tlie  ph\ster,  and  in  spite  of  it.  will  appear  or  reap 
pear  (fig.  43,  44-  4j). 

And  even  the  formula  that  the  two  adjacent  articulations  should 
be  included  is  insufficient  in  manv  cases:  for  example,  in  a  coxitis 
during  the  acute  stage,  one  should  include  below,  not  only  the  adja- 
cent articulation  (that  is  to  sav  the  knee),  but  even  the  entire  foot. 


wliich  says  tliat  the  two  adjacent  articulations  must  be  included  in  the  jilasler 
was  here  adhered  lo  :  that  formula  is  then  insufficient  in  certain  ca-cs. 


62       2"'°    CONDITION'    :    THE    PLASTER    MUST    BE    CAREFULLY    MOULDED 

Still  further  :  in  alTections  of  the  spine,  in  an  osteitis  of  the  tenth 
dorsal  vertebra  for  example,  it  >vould  be  altogether  insufficient,  and 
even  ridiculous,  to  include  in  the  apparatus  only  the  two  articula- 
tions next  to  the  affected  part.  And  for  orthopedic  affections  of  the 
back  whatever  may  be  the  scat,  you  must  include  in  the  apparatus, 
if  not  ahvavs  the  base  of  the  cranium,  at  least  the  scapular  and  pelvic 
girdles  (shoulder  and  pelvis). 

We  will  mention  elsewhere,  in  studying  the  different  maladies, 
the  dimensions  to  be  given  these  apparatus,  in  each  instance. 

b)  The  plaster  must  be  carefully  moulded  over  the  region. 

It  should  be  as  exact  as  if  it  w  ere  applied  to  the  skin  itself.  One 
mio-ht,  strictly  speaking,  apply  the  plaster  to  the  skin  as  is  done  in  the 
attelles  of  Maisonneuve,  in  fractures  of  the  legs.  But  the  plaster 
adheres  to  the  hair,  its  direct  contact  is  disagreeable,  especially  if 
made  with  cold  water,  which  is  the  rule,  it  might  have  grave  incon- 
veniences when  it  is  a  question  of  a  thoracic  plaster;  its  removal 
would  be  also  more  difficult.  For  all  these  reasons,  and  also  to  en- 
sure the  cleanliness  and  good  condition  of  the  skin,  it  is  better  to  cover 
it  Avith  a  soft  tissue,  —  but  with  the  proviso  that  nothing  be  omitted 
to  ensure  the  accuracy  of  the  apparatus,  —  a  condition  AAhich  is  evi- 
dently not  always  fulfilled  when,  as  is  often  done,  coverings  of  cotton 
Avool  of  several  lingers  in  thickness  are  used. 

It  is  impossible,  with  a  plaster  applied  over  such  a  thick  cushion, 
to  control  Avith  precision  a  fragment  of  bone  which  is  pointing,  spi- 
nous processes  Avhich  project,  lips  of  articulations  Avhich  tend  to  be 
deviated.  It  is  impossible,  especially  after  some  Aveeks,  or  may  be 
months  Avhen  the  cotton  avooI  has  been  crumpled,  and  that,  ahvays 
unevenly.  This  explains  Avell  how^  it  is  that  plasters,  applied  to  limbs 
straio-ht  or  redressed,  generally  yield  limbs  or  the  trunk  deformed  (in 
Pott's  disease,  hip  disease,  or  fractures). 
What  is  to  be  done  ? 

When  you  have  only  cotton  wool  at  your  disposal,  you  may  use 
it,  provided  that  you  apply  only  a  very  thin  layer,  as  thin  as  possible, 
but  uninterrupted:  say,  to  fix  your  ideas,  a  layer  of  one  and  a  half  to 
tAvo  millimetres,  spread  out  very  evenly. 

But,  as  you  may  guess,  this  is  not  to  be  done  Avithout  difficulty; 
and  it  is  for  this  reason  that  I  advise  you  never  to  make  use  of  cot- 
ton wool  except  in  case  of  necesssity,  and  to  prefer  the  fourreau 
of  soft  tissue. 

The  fourreau  you  Avill  find  everyAvherc.  It  is  for  the  leg  (as  for 
the  upper  limb)  a  jersey  sleeve  or  two  jersey  sleeves  placed  end  to 


A    GOOD    PLASTEK    MUST    NOT    CAUSE    DISCOMFORT  03 

oiul  ;  il  is,  lailiiii;  a  jcrscv  sIceNC,  an  oidliiary  sociv  for  llic  leg  and  llic 
Tool:  il  is.  I'oi'  llio  liiink.  an  indiiiary  jcrscN.  anil  Ibr  llic  large 
a{)|)araUi.s  lor  llie  lower  limb,  slill  a  jersoy,  but  jhiL  on  after  the 
manner  of  a  pair  of  drawers. 

If  (lie  fabric  of  llic  fonircan  is  too  lliln,  pnlon  two'. 

So  niucli  for  the  covering  of  the  skin.  Xow  for  ibc  mode  of 
applying  the  bandages. 

I  have  said  that  il  is  not  sufficient  lo  apply  Ihe  strips  exactly,  thai  il 
Is  necessary  moreover  lo  mould  the  plaster  around  the  projections  of 
the  region;  this  moulding  applies  especially  to  plasters  of  the  pelvic 
region  and  the  Irunk  (we  ■will  return  to  this  a  propos  of  the  apparatus 
for  coxitis  and  Pott's  disease). 

I  have  spoken  also  of  the  nccessitv  of  maintaining  the  position 
of  the  limb  until  the  plaster  has  set,  but  I  wish  to  insist,  because 
this  rule  is  violated  every  day  in  the  greatest  part  of  surgical  practice. 
Bring  to  TOur  mind  what  often  occurs  :  The  •'  chief  "  refuses  to 
remain  any  longer,  judging  that  his  importance  calls  him  to  more 
noble  duties;  he  hands  over  the  task  of  maintaining  the  position  to 
an  externe  or,   to  an  oblia;ins:  friend  who  is  not  slow  in  losing  his 

'DO  O 

patience  in  his  turn,  in  front  of  this  plaster  which  will  not  dry  (too 
often  the  plaster  of  hospitals  refuses  to  dry,  being  decomposed),  and 
he  lets  it  go  before  it  is  "  set  "  :  the  correction  is  lost  in  parts  or 
altogether  and  thus  the  final  result  is  lost  or  compromised. 

You  should  keep  up  the  support  right  up  to  the  setting  which 
will  only  require  a  few  minutes,  if  you  have  taken  care  to  procure 
good  plaster  and  tested  it  beforehand,  every  time  you  have  to  cons- 
truct a  new  apparatus. 

B.  —  HOW  TO  MAKE  A  PLASTER  WHICH  WILL  NEITHER 
BE  UNCOMFORTABLE  NOR  CAUSE  INJURY. 

And  first,  an  axiom  :  a  good  plaster  must  not  cause  discomfort. 

On  the  contrarv,  it  should  give  a  sense  of  security  and  of  perfect 
comfort  just,  for  example,  as  a  well  made  boot.  The  patient  ought 
to  feel  more  easv  with  it  than  without  it!  This  is  true  to  the  letter: 
children  who  are  taken  out  of  a  good  plaster  are  impatient  to  return 
to  it. 

I.  The  tissue  of  the  Pyrenees  and  the  lint  recommended  in  some  books 
are  not  sul'flcientlv  delicate. 


"4 


110V\     TO    MAK.E    GOOD    PLANTERS 


But  let  there  be  no  misuuclcrstanding.  It  may  be  that  Avhcn  it  is  a 
question  of  a  first  plaster,  the  patient  complains  of  slight  discomfort 
durino-  the  first  few  davs,  Avithout  there  being  any  bad  workmanship 
of  the  plaster,  without  auA"  other  reason  than  that  of  being  unaccusto- 
med to  it.      Thus  an  adult  on  whom  a  large  plaster  is  applied  for 


Fig,  !\G.  —  ANliat  is  not  to  be  done   ;  do  not  pull  on  the   bandage  and  cause  csdema 

of  the  limb. 


Pott's  disease  is  liable  to  complain  of  a  little  discomfort  during  the 
first  fortA"  eight  hours,  even  with  a  well  made  plaster. 

In  such  a  case  one  does  not  re-make  the  apparatus  (nothing  is  to 
be  gained  bv  it).  It  is  necessary  onlv  to  help  the  patient  Avith  soo- 
thing draughts  and  a  few  kind  words,  to  pass  the  first  few  rather 
unpleasant  hours.  —  assuring  him  that  to  this  discomfort  will  soon 
succeed  perfect  comfort ' . 

And,  even  more,  Avhen  the  plaster  has  been  applied  for  a  grave 
injury  or  after  the  laborious  or  painful  correction  of  some  deiormity, 
the  patient  mav  be  expected  to  experience  some  pain  during  the  first  few 

I.  AVe  will  describe  apropos  of  the  plaster  corset,  the  means  of  suppress- 
ing almost  entirely  this  discomfort  by  making  slight  temporary  modifications 
in  the  plaster. 


Tin;    MOSI     ACCLR.VTE    PLVSTI-K    IS    THE     HEST    TOLEU.VTED  ()") 

davs.  willioul  one  iiccossaiih  iiircrriiii:  llial  the  plasler  is  at  faiill.  Tim 
jjaiii  will  pass  oil"  tjradnallN .  w  lioreas,  //(  a  bvUv  nuvle  pldsler  tin-  pniii 
would  go  on  increasiiKj . 

Wc  will  sec  first  : 

Why  a  plaster  incommodes,  injures,  or  causes  troubles 
of  nutrition. 

It  is  lirsl  because  it  is  not  accurate.  —   'J'lic  first  condilion 


Vi'^.  '4-  and  i8.  —  \Miat  it  is  not  necessary  to  do.  Tlie  foot  is  liold  in  (lie  position 
ofequinus  up  to  the  moment  of  applying  the  plasler  and  it  is  not  straightened  until 
immediately  afterwards  (see  explanation  of  following  lisure). 

Fig.  ^8.  —  The  food  plastered  in  extension  (vide  preceding  figure)  is  carried  imme- 
diately afterwards,  before  the  plaster  sets,  to  an  angle  of  90°;  creases  are  formed 
in  front  of  this  angle  and  will  nearly  certainly  bring  about  a  slough,  or  compro- 
mise a  vessel. 


\\liicli  tlie  plaster  should  lultil  in  order  to  be  tolerated,  is  accuracv. 
One  might  believe,  at  first,  that  a  verv  accurate  plaster  would  be  a 
troublesome  plaster:  well,  it  is  the  contrary  that  is  true;  it  is  the  verv 
loose  apparatus  which  brings  about  bv  its  shaking,  its  incessant 
movement,  a  friction  ot"  the  projecting  parts  of  the  plaster  against 
the  prominent  parts  of  the  bodv,  which  friction  mav  possiblv  produce 
a  slough. 

\\  bile,  with  well  modelled  apparatus,  the  reliefs  of  the  bodv  are 
fitted  immoveablv  into  the  depressions  of  the  apparatus,  and  there 
are  no  scars,  or  practicallv  none,  to  be  afraid  of.     But.  this  need  not 

Cai-ot.   —  Indispensable  orthopedics.  5 


66     TO  MAKE  AN  ACCURATE  PLASTER  BUT  NOT  TOO  TIGHT 

surprise  you  since  everyone  knows  that  a  liorse  is  injured,  not  by  a 
tight  collar,  but  by  a  loose  one. 

We  have  already  mentioned  the  method  of  making  well  fitting 
plasters,  we  will  not  return  to  it. 

Second,  because  it  is  too  tight  at  one  point,  or  all  over. 
Like  a  well-made  boot,  a  plaster  can  and  should  be  accurate  ivilhout 
being  tight. 

The  principal  cause  of  tightness  in  a  plaster,  is  that  the  bandages 
have  been  pulled  upon  too  much  when  applied.  We  have  mentioned 
that  it  is  a  fault  Avhicli  beginners  commit  very  often;  they  have  a 
tendency  to  pull  upon  a  plaster  bandage  as  they  pull  upon  an  Esmarch 


Fig.  49.  —  Jn  case  you  should  have  committed  the  fault  indicated  in  fig.  /17  and  /i8, 
here  is  the  way  to  remedy  the  formation  of  creases  represented  in  fig.  -'|8  :  you 
CDntrive  a  square  opening  in  front  over  the  ankle. 

bandage.  It  is  necessary  then  to  guard  against  causing  oedema  of 
the  limb.  Do  not  think  there  is  need  to  pull  on  the  bandage  in  order 
to  apply  it  exactly.  No,  it  is  sufficient  to  unroll  it  exactly  over  the 
circumference  of  the  limb,  as  if  one  had  to  take  an  impression  of  its 
contour,  as  it  were,  without  subtracting  anything,  without  adding 
anything.     Therefore  do  not  pull  upon  the  bandages. 

But   there   are   other   reasons    for   the   plaster   being   too    light. 

1"  Because  the  assistant  who  held  the  foot  has  drawn  or 
pressed  strongly  upon  the  apparatus,  before  the  plaster  was  set. 
It  seems  hardly  possible  to  avoid  these  tractions  or  vigorous  pressures, 
Avhen  the  foot  itself  has  a  tendency  to  deviate. 

One  can  do  it  however,  by  making  it  an  absolute  rule  to  correct 
all  somewhat  obstinate  deformities  before  applying  the  plaster,  and 
not  to  add  in  any  way  to  this  correction  afterwards. 

2°  For  deformities  of  the  foot,  if  one  tried,  after  having  constru- 
ted  the  plaster  on  the  foot  in  extension,  to  roughly  fiex  the  foot  upon 
the  leg  (fig.  47  &  48)  a  buttress  would  be  produced  in  front,  a  plaster 
ridge,  capable  of  producing  a  blister,  or  even  of  arresting  the  circula- 


1(»     \Vi>ll)    I'l  I.I.IXC    L'l'ON     l'I,\Sll!:i\KI)    HAM)AOES  67 

lion  in  llio  loot.  I(  wdiild  sul'lico  il  is  tnio.  lo  provciil  ail  annoyance, 
to  make  an  opi'iiiny  in  lln-  apparal  ns  in  IVoiil,  in  order  to  remove 
this  |)ressnre  of  I  lie  plaster  (li^^  /igj. 

Aiiollier  precaution  :  the  assistant  will  change  places  with  his 
hands  I'roni  lime  lo  time,  change  his  hold,  whilst  the  plaster  is 
drviny  :  a  conliniious  and  prolonged  pressure  al  llie  same  pnini  may 
make  a  depression  in  the  plaster. 

Lasllv,  it,  in  spite  ol'  evervlhing,  there  remains  on  the  surl'ace  ol' 
the  plaster  llallened  or  deep   impressions  (fig.   5o),  caused  by    the 


Fig.  5o  —  During  the  drying  of  ttie  plaster  depressions  may  be  produced  liy  tlie  side 
of  ttie  table  upon  Avhich  the  patient  has  been  lying,  or  by  the  hands  -which  have 
been  supporting  the  correction.     Here  is  a  specimen  of  such  depressions, 

application  of  the  hands,  one  will  make,  immediately  after  the 
setting,  openings  at  these  points,  replacing  afterwards  the  pieces 
removed  by  squares  of  plastered  pads,  or  bv  some  turns  of  plastered 
bandages  (fig.  5i). 

This  is  how  you  can  always,  or  neaily  alwavs,  prevent  the  plaster 
from  being  troublesome.  I  say  nearly  always,  for  there  are  excep- 
tional cases  Avhere  a  plaster,  however  well  made,  may  cramp  or 
wound  the  patient,  owing  to  the  nature  of  the  lesions  or  to  his 
generally  bad  condition. 

1*'.  Because  of  the  lesion  :  for  example,  a  pointed  gibbosity  or 
a  fragment  unusually  prominent  in  some  fracture  of  the  tibia  or  of 
the  clavicle  may  have  ulcerated  the  skin  without  any  fault  having 
been  committed  in  the  making  of  the  plaster. 


68 


TO    AVOID    PULLIXG    UPO>"    PLASTERED    BAXDAGES 


But,  one  can  alwavs,  or  nearly  ahvavs  save  tlie  Integument,  even 
in  that  case,  if  one  takes  care  to  make  an  opening  in  the  plaster 
immediately  after  its  completion. 

2.  Because  of  the  subject;  for  example,  in  some  paralysed  suh- 
jects,  the  simple  Aveight  of  the  limh  may,  strictly  speaking,  cause  a 
slough  in  the  sloping  parts,  and  the  mere  Aveight  of  the  plaster  pro- 
duce a  slouD-li  in  front. 

D 

And  you  mav  see  that  also,  though  in  a  less  degree,  in  verv 
cachectic  subjects. 

Finally,  Ave  must  say  that  Ave  mav  meet  Avilh  intolerant  skins. 


Fig.  5i.  —  One  raises,  as  shewn  here,  or  betler  slill  one  picks  out  the  parts  crushed  in 
and  at  once  closes  the  openings  by  means  of  square  plasters,  or  a  few  turns  of 
plastered  strips. 


bearing  contact  Avith  plaster  badlv.  becoming  immediately  eczema- 
tous.  But,  let  us  assure  vou,  that  this  is  met  Avith,  hardly,  once 
in  a  hundred  cases. 

The  Method  of  treating  wounds  or  trouble  with  nutrition  of 
the  skin. 

In  pointino-  out  the  causes  of  these  troubles  Ave  liaA'C  indicated  at 
the  same  time  the  means  of  guarding  against  them,  that  is  to  sav. 
their  preventive  treatment. 

If  ihese  troubles  do  arise,  this  is  the  method  of  rcmedAing  them  : 

First  case.  —  There  are  troubles  with  the  circulation  and 
the  innervation  of  the  limb. 

These  troubles  are  easily  detected;  it  is  sufficient  to  examine  the 


ro    HI-MliDV     rilOl  IILES    OK    NLTIUTION    AND    %VOUNDS  6o 

Iocs  and   llial  is  wlial  one  slionlii  al\\a\s  think  ol'  when  a  plaster  is 
jnsl  linislnHl. 


Fig.   32.  —  This  plaster  was  too  tiglit  ia  its  whole  extent;  it  has  been  split  from  top 
to  bottom  and  the  edges  separated. 

These  troubles  are  due  to  the  fact  that  the  phaster  is  too  tight 
everywhere. 


Fig.  53.  —  This  plaster  was  too  large  ;   a  tongue  shaped   portion  has  been  removed 
in  the  median  line. 

In  order  to  relieve  the  constriction,  it  is  not  necessarv  to  remove 
the  apparatus,  it  is  suificient  to  loosen  it  by  simply  splitting  it  in  the 


■JO  THE    METHOD    OF    RE-ADJL"STI.\G    A    PLASTER    TOO    LARGE 

median  anterior  line,  in  the  manner  mentioned  on  page  !^l  and  fig.  52. 
A\  hen  this  anterior  incision  of  the  plaster  and  the  consequent 
separation  of  the  two  lips  have  not  entirely  put  matters  right,  not 
bringing  back,  for  instance,  the  return  of  sensibility,  as  "well  below 
the  toes  (or  fingersj,  as  above,  vou  should  open  the  apparatus  behind 
and?  better  still,  remove  it  completely  and  change  it,  guarding  this  time 
against  the  fault  comitted  before  (of  applying  the  strips  too  tightly) 


Fig.  54  —  Tiie  median  tongue  has  been  taken  out,  the  phisler  is  then  readjusted  Lv 
bringing  together  the  sides  "which  are  maintained  in  contact  h\  turns  of  plastered 
strips. 

But,  once  again,  if  you  are  careful  never  to  leave  your  patients 
w"ho  have  had  apparatus  fitted,  without  satisfying  vourself  that  the 
nutrition  of  the  toes  and  fingers  is  normal,  or  is  becoming  normal 
again,  xou  Avill  never  have  anv  serious  trouble. 

V^  e  will  allude,  in  passing,  to  the  case  of  the  plaster  which  is 
too  loose. 

This  arises,  as  we  have  said,  througli  the  strips  not  having  been 
exactly  applied  ^. 

I .  Except  however,  in  the  case  of  fractures  with  swelling  of  the  limb 
In  that  case  a  plaster  fitting  on  the^  first  day,  will  not  do  so  a  week  or  two 
afterwards  (v.  p.  82). 


WIIAI-     l(>     IHi     WIIKN     Till-:     I'LASTI.K    GALSliS     I'AIN  -J  I 

Can  il  !)(•  iciiKMruML'      \('s,  in  llic  lollowin^  inaiiiior. 

The  manner  of  readjusting  a  plaster  which  is  too  large. 

\o\i  inalu"  an  incisuMi  aloiii^  llic  niidillc  I'me  in  Ironl,  culling  oul 
iVoni  ono  side,  ov  IVoni  holli,  Irom  lop  to  botlom,  a  strip  of  plaster, 
one,  two.  or  three  centimetres  wide;  alter  that  you  bring  together  ihc 
sides  and  lix  them  with  a  square  of  plastered  muslin,  encroaching  on 


Fig.  55.  —  A  slain  produced  by  a  slough  :  this  stain  is  tinted  more  deeply  at  the 
centre  than  at  the  periphery;  it  is  not  got  rid  of  by  scraping  the  surface  of  the 
plaster;  on  the  contrary,  it  becomes  more  evident  the  more  deeply  the  knife  sinks 
into  it. 

the  two  edges,  or  else  Avith  some  turns  of  bandage  (fig.  53  and  54)- 
But,   in  this  case,  it  is  still  more  simple  and  more   perfect   to 
replace  the  apparatus  altogether.     You  should  replace  it  in  the  case 
of  a  fracture,  after  the  swelling  of  the  limb  has  disappeared. 


Second  case.  — There  exist  pain,  excoriations,  or  sloughs. 

Here  the  patient  complains,  one  or  several  days  after  the  construc- 
tion of  the  plaster;  he  indicates  a  pain  at  a  parlicular  point ;  at  the 
heel,  the  malleoli,  or  the  knee.  We  have  said  that  this  ought  not  to 
be,  that  it  Avas  not  in  the  programme.  It  behoves  you  to  seek  for 
he  cause  b\  making  an  opening  in  the  plaster,  at  this  poml. 


72 


SIGNS    ODICATIVE    OF    SLOUGHS  ;     I.     FEVER;     2.     PAIN: 


The  skin  being  laid  bare; 

i"*'.  One  finds  nothing  abnormal,  or,  simply  that  the  skin  is 
slightly  reddened.  In  both  cases,  you  powder  with  talc,  and  close 
the  opening  with  a  square  of  cotton  wool  and  a  few  turns  of  soft 
bandage,  taking  care  to  inspect  it  again  if  the  patient  complains. 

2.   There  is  already  a  small  slough. 

Sloughs  are  exceedingly  rare,  if  you   have^  made  no  mistake   in 


Fig.  56.  —  The  first  kind  of  slough ;  that  which  excavates,  that  which  destroys.  It 
is  seen  especially  in  cachectic  subjects.  This  variety  is  less  benign  than  the  follow- 
ing one  (fig.  5  7). 

Its  treatment  :  To  stimulate  by  the  application  of  tincture  of  iodine,  of  \igo  plas- 
ter, etc.,  the  vitality  of  the  mortified  tissues. 

the  technique.  Nevertheless,  they  may  be  produced  quite  apart 
from  any  fault  in  technique,  as  Ave  have  said,  in  cachectic  subjects. 
They  may  even  be  produced  at  any  time,  by  the  penetration,  beneath 
the  plaster,  of  a  foreign  bodv,  small  particles  of  plaster  or  of  sand, 
various  articles  introduced  by  the  patients  themselves,  buttons,  me- 
dals, coins,  hooks,  pencils,  etc.,  or  even  by  the  repeated  soiling  of  the 
skin,  with  urine,  pus,  etc. 

How  to  discover  the  slough. 

One  is  warned  by  four  signs,  which  are,  in  ascending  order  of 
frequency  ;  a)  a  slight  elevation  of  temperature  ;  h)  a  localised  pain ; 
c)  a  staining  apparent  on  the  surface  of  the  plaster ;  d)  a  disagreeable 
odour  emanating  from  the  plaster. 


o.    visiiii.i:   siAi\iN(;;    'i .    ii/iidiiy  oi    nn:    i'i.\sri:u  -j.S 

It.  Snmoliincs,  llioii^li  vory  rarely,  il  is  aniniiinccd  I)n  a  sli'lil 
riso  ol  Icmpcralurc. 

ir,  in  a  plasl(M'('il  suhjoct  avIio  has  had  no  lisc  of  Icmpornliirc 
before  the  applicalidn  of  (he  plaster  and  has  nol  liccii  redressed  nor 
sustained  any  serious  aecideni,  (here  occurs  a  sliij;hl  evening  fever  of 


P  V 


Fig.  57  Fig.  58 

Fig.  67.  —  The  second  kind  of  slough  :  that  whicli  fungates  (cauliflower).  In  tlie 
preceding,  there  was  mortification  of  the  tissues,  here  there  is  over-production. 
This  second  variety  is  very  benign.  —  One  finds  it  especially  in  subjects  of  good 
general  nutrition.  —  Treatment  :  Get  rid  of  the  exuberant  tissue  by  caulerizalions 
of  nitrate  of  silver  or  the  thermo-cautery. 

Fig.  58.  —  The  second  variety  of  slough  (fungating),  a  stage  fuiiiier  advanced. 
It  shows  itself  in  the  form  of  a  "  mushroom  "  or  of  "  cock's-comb  ":  sometimes 
very  large  with  a  delicate  pedicle.  One  cuts  this  pedicle  with  scissors,  or  destroys 
it  with  a  pencil  of  nitrate  of  silver,  as  in  this  figure. 

38°  to  38,5°  after  one,  tAvo  or  three  Aveeks,  one  ought  to  think  of  the 
possibility  of  a  slough  having  formed. 

Look  immediately  and  see  if  you  can  find  a  disagreeable  odour 
from  any  part  of  the  plaster;  if  you  do,  make  an  opening  at  that 
point.  If  you  do  not,  and  in  case  of  doubt,  —  after  having  Availed 
eight  or  fifteen  days  at  the  most  —  cut  the  plaster  in  two  halves,  in 
order  to  make  a  complete  examination  of  the  region. 

And  you  Avould  do  the  same,  if  after  having  found  a  slough  and 
having  dressed  it  through  a  small  opening,  you  find  fever  persist- 
ing Avhich  is  not  explained  bv  the  said  slough:  in  that  case^  cut  the 
plaster  in  two  halves,  to  assure  vour.self  there  is  no  slough  elsewhere. 


74  RAPID    TREATMENT    AND    CURE    OF     SLOUGHS 

b.  Pretty  often,  it  is  the  pain  persisting  at  one  point,  ahvays  the 
same  one,  (over  a  malleolus,  the  heel,  the  iliac  spines,  the  sacrum, 
the  knee)  which  discloses  the  slough. 

At  the  seat  of  the  pain,  you  make  an  opening  in  the  plaster. 

c.  More  often  still,  you  are  attracted  by  the  appearance  of  a 
brown  stain  on  the  surface  of  the  plaster.  Do  not  confuse  this 
with  the  staining  produced  by  urine,  which  gives  the  odour  of  urine 
and  not  of  pus :  it  is  rather  yellowish  and  disappears  on  scraping  the 
surface  of  the  plaster,  Avhereas  the  discoloration  produced  by  sloughing 
persists  in  spite  of  scraping  (fig.  55). 

d.  But  the  most  characteristic  sign  of  sloughing,  is  the  dis- 
agreeable odour  emitted  by  the  plaster  at  one  point ;  it  is  a  special 
odour  comparable  to  the  odour  of  pieces  of  old  dressing  imprcgnaled 
with  pus*,  an  odour  which  makes  itself  apparent  if  one  puts  one's 
nose  near  the  apparatus. 

I  have  an  attendant  who  passes  his  nose  from  time  to  lime  over 
the  apparatus  and  quickly  ferrets  out,  even  a  commencing  slough, 
to  a  certainty. 

Here,  smelling  is  better  than  seeing. 

How  to  treat  a  slough  (fig.  56,  57  &  58). 

It  is  not  necessary  to  remove  the  apparatus,  it  is  sufficient  lo 
make  an  opening-  at  the  place  indicated  by  the  discoloration  of  the 
plaster  or  by  the  characteristic  odour.  The  slough  being  exposed 
and  uncovered  for  three  or  four  centimetres  from  the  edges  of  the 
opening  of  the  plaster,  you  cleanse  it,  rub  over  with  nitrate  of 
silver  the  fungating  wound,  and  then  treat  it  with  a  layer  of  pow- 
dered talc,  or  Avith  vaseline  sterilized,  or  with  naphthalan  pommadc 
You  dress  it  every  day  until  it  cicatrizes,  which  it  does  very  quickly 
(in  6,8  or  10  days). 

1.  And  yet,  this  very  disagreeable  odour  does  not  signify,  absolutely,  the 
existence  of  a  slough;  the  most  disagreeable  odours  are  due  to  a 
discharging  eczema  more  often  perhaps,  than  to  a  real  slough.  But,  in 
both  cases,  it  is  necessary  to  examine  and  treat  the  skin.  l^ou  treat  these 
eczemas  with  sterilized  talc  (rather  than  with  vaseline),  or,  with  daily 
applications  of  a  layer  a  millimetre  thick,  of  a  black  pommade  known  as 
naphthalan,  and  better  still,  by  radiotherapy,  or  ex^DOsure  to  open  air  or  the 
sun. 

2.  In  the  exceptional  case  of  multiple  sloughs,  one  turns  the  plaster  into 
a  bivalve,  which  allows  one  to  make  the  dressing  without  neglecting  the 
support  of  the  limb. 


now    ro   I'HF.M.M'  SA\  r.i.LiMc;  oi-   the  free  extremities      ~,> 

Cii\oii  lliesc  iiuluatious,  you  should  know  how  (o  avoid  sloughs, 
or.  if  in  spile  of  cvcrylhing,  ihcy  occur,  to  recognise  them  quickly 
and  euro  them  v(my  easily,  —  in  this  ^vay  a  sloupli  ought  lo  he  a 
negligcahle  incident. 

Anolher  incident  possiljic  alter  the  application  of  a  plaster  (and 
which  I  wish  to  [loinl  out,  hcing  desirous  of  omitting  nothing  ■which 
nia\  i)e  useful  to  von  ) ;  ^\  lieu  you  have  stopped  applying  a  plaster  of 
the  lower  lind)  (or  of  the  upper)  for  'a  more  or  less  considerahle  dis- 


Fig.  69.  —   A  pla^ler  wliicli  does  not  reach  to  llio  exlieuiilv  ul 
it  has  produced  a  swelling  of  the  free  part. 


tance  from  the  toes  (or  fingers)  you  may  possibly  see  a  swelling  of  the- 
free  extremity  of  the  limb  (fig.  Sg). 

What  is  to  be  done  in  that  case  ?  Invariably  the  parents  propose 
to  you  to  pare  down  a  little  of  the  lower  border  of  the  plaster.  But 
if  you  cut  it  (or  pare  it)  you  will  find  the  swelling  will  appear 
higher  up.  Instead  of  cutting  the  apparatus,  as  the  parents  request 
you  to  do,  it  would  be  better  to  lengthen  it ;  instead  of  freeing  the 
limb,  it  would  be  better  to  bandage  the  free  portion,  and  that  is 
indeed  Avhat  you  will  do  (fig.  60). 

You  yvill  apply,  then,  over  the  swollen  part  of  the  limb,  a  cotton 
wool  dressin;?:  aentlv  introduce  a  little  of  this  cotton  wool  (a  layer 
2  or  3  millimetres  thick)  bet^veen  the  lower  border  of  the  plaster  and 


nQ  INFA>"TS     A>D    AGED    PERSONS    MAY    BE    PLASTERED 

the  skin,  and  you  ^vill  afterwards  enclose  this  wool  dressing  T,vith  a 
soft  muslin  bandage,  or  better,  with  one  of  Yelpeau  bandage,  going 
methodically  from  the  extremity  of  the  limb  up  to  the  plaster,  and 
overlapping  that  ^vith  one  or  tAvo  turns  of  bandage. 

You  bandage  the  leg  in  the  same  Avay  from  the  toes  up  to  the 
knee,  if  it  is  a  question  of  a  swelling  of  the  leg  or  foot,  due  to  an 
apparatus  stopping  at  the  knee. 

It  is  the  same  for  the  upper  limb. 


Fio-.  60.  —  In  the  case  of  swelling  of  the  free  part  of  the  limb,  do  not  pare  round 
the  lower  border  of  the  plaster,  but  make  a  slit  longitudinally,  following  the  axis 
of  the  limb  to  the  extent  of  3  or  4  centimetres,  then  raise  gently  the  edge  of  the 
apparatus  in  order  to  pass  between  it  and  the  skin,  a  layer  of  wool;  afterwards  com- 
press a  little  the  free  part  of  the  limb  with  a  Velpeau  bandage,  commencing  at  the 
toes  and  rising  up  to  the  border  of  the  plaster. 

Look  at  it  the  same  evening  or  the  next  day  and  you  will  see 
that  the  swelling  has  already  almost  completely  disappeared;  re- 
apply the  same  compressive  avooI  bandage,  and  renew  it  every  two  or 
three  days,  until  the  tendency  to  SAvell  no  longer  exists. 

If  it  persist,  provided  it  is  only  a  slight  degree  of  swelling,  no 
inconvenience  will  be  caused  by  continuing  this  slightly  compressive 
treatment. 

But,  If  the  tendency  is  too  marked  and  persists  beyond  fifteen 
days,  you  slacken  the  plaster  by  splitting  it  from  top  to  bottom:  you 
afterwards  separate  the  two  edges  by  2  or  3  centimetres  and  keep  up 
this  separation  after  the  manner  described  at  p.  68,  in  the  case  of  a 
plaster  which  is  too  tight. 


now    TO    \\oii)    \i,i.    \ccini:MS    w  1 1  ii    iiir,   i-lastku  --y 

I'iiiallv,  dill'  last  rciiiaik:  ii'lirn  nn  ojicniiKj  is  made  in  llic  plaster, 
it  iiHisl  ahvavs  be  closed,  olliciw  isc  llic  skin  would  he  cut  against  the 
sides  of  the  openings,  ^ou  reclose  it  1)n  applviny  over  the  exposed 
part,  squares  of  wool  tlie  sides  of  which  arc  lightly  packed  betw  een 
the  edges  of  the  jilasler  and  llie  skin,  and  kept  in  position  bv  several 
turns  of  soil  bandage  exerting  a  certain  amount  of  compression. 
(V.  p.  5o). 

Is  there  no  formal  centra-indication  against  the  emploj'mer.t 
of  Plaster.  For  example,  the  age  of  the  subject?  No  :  it  is  pos- 
sible to  plaster  the  very  young  (for  example  for  club-foot)  as,  also, 
very  aged  persons  (for  example,  for  a  fracture). 

Simply,  it  Avill  be  necessary,  in  those  as  in  the  paralysed  and 
cachectic,  to  make  an  inspection  nearly  every  day.  inspecting  the 
nutrition  of  tlie  toes  (or  the  fingers)  by  \\Iiich  means  vou  ^^ill  avoid 
any  disagreeable  surprise. 

In  small  children,  because  of  tlie  frequent  soiling  of  tlie  plaster, 
it  would  perhaps  be  advisable  to  change  the  apparatus  rather  more 
often  —  it  is  onlv  a  little  inconvenient  after  all. 

Resume  and  Conclusions. 

You  see  that  I  have  not  hidden  from  vou  any  of  the  incidents  or 
accidents  possible  after  the  construction  of  a  plaster.  I  have  done  so 
to  give  you  the  possibility  and  facilitv  of  being  on  your  guard.  But. 
I  should  have  failed  in  mv  object  and  I  sliould  have  misrepresented 
things  if  I  had  left  you  Avith  the  impression  that  it  is  a  "  horribly 
difficult  "  thing  to  succeed  Avith  a  good  plaster,  and  that  with  the 
presence  of  so  manv  pitfalls  to  avoid,  Avith  so  many  dangerous 
headlands  to  double,  it  would  be  better  not  to  venture  Avith  it.  Such 
a  conclusion  Avould  be  in  reality  a  complete  error,  very  prejudicial 
to  your  patient  and  yourself  so  that  it  is  my  duty  to  dissipate  it. 

No  :  to  sum  up  evervthing,  when  you  have  a  plaster  to  make, 
spread  vour  bandages  accurately,  but  without  pressure  or  traction ; 
mould  the  plaster  afterwards  bv  pressing  it  around  the  prominences 
and  not  over  them:  correct  bad  positions  before  applying  the 
[)lastcr:  maintain  this  correction  Avithout  altering  it;  make  an 
opening  in  the  plaster  immediately  after  it  is  set  if  it  appears  to  be 
too  depressed  at  am  poinl;  split  it  from  top  to  bottom,  ifyou  consi- 
der,from  the  condition  of  the  toes,  that  it  is  too  tight  in  its  entire  length. 

All  this  is  sulficicnt  —  and  there  is  no  "  sorcery  "  in  it  — to 
avoid  all  accidents,  or,  at  least,  all  serious  accidents. 


78 


now    TO    MARE    ELEGA>T    PLASTERS 


C.   _  HOW  TO  MAKE  ELEGANT  PLASTERS 

The  ideal  as  >ve  have  said,  is  to  make  plasters  not  only  comfor- 
table and  accurate,  but  even  elegant;  to  unite  to  the  into  the  jucunde. 
Besides,  the  t^o  things  go  nearly  ahvays  together.  An  accurate 
plaster  could  not  be  ugly,  because  it  reproduces  the  form  of  the 
human  bodv.  But  if,  in  addition  to  this  regularity  you  give  to  the 
surface  a  polish  and  a  brilliancy,  then  it  will  be  perfect. 


Fig.  6i.  —  The  apparatus  in  the  rough  before  polishing. 


And  do  not  think  that  this  prepossession  for  making  elegant  plas- 
ters is  of  no  importance  in  practice;  on  the  contrary,  it  is  by  this 
that  the  relatives  judge  you  most  often! 

And  by  what  you  Avould  expect  them  to  judge  you,  before  a 
definite  result  has  been  obtained,  which  may  require  several  months, 
or  even  years?  By  what,  if  not  on  comfort  (or  discomfort)  due 
to  the  apparatus,  and  by  the  elegance  (or  the  ugliness)  of  that  appa- 
ratus? Therefore,  train  yourself  and  spare  no  trouble  to  make 
elegant  plasters. 

In  place  of  a  clumsv  piece  of  work,  strive  to  make  Avhat  I  mav  call 


iiii;    i'iii.i<iiiN(;   (II-    i'i,vsri;K    mm'.vu.vtus 


79 


a  work  ol  ait.      ^  on  will  ix"  a!)lo  lodr)  il  if  \(iii  scLvour  mind  on  il  '. 
Ill  Older  lo  protliuc  an  clrj^aiil  [ilaslcr,  one  polishes  it. 

The  polishing  of  the  plaster. 

Tlioro  arc  two  procesess ;  first,  immediate  polishing,  doiio  as 
soon  as  vou  have  rolled  llic  h\st  plastered  slrip,  bcibre  ihe  plaster  sets. 

The  second,  late  polishing,  done  ivlien  Ihe  plaster  is  dry,  that  is  to 
sav  two  or  llirec  days  after  its  construction. 


Fig.  62.  —  The  plaster  apparatus  polislied.      The  polisliing  has  liad  tlie  effect  of  elTacing; 
Ihe  external  roughness  and  rendering  the  apparatus  smoother  and  more  glossy. 


The  first  process,  the  most  convenient,  the  most  rapid,  has  not  the 
same  aesthetic  value  as  the  second  but  it  is  nevertheless  sufficient,  and 
it  is  that  Avhich  I  advise  vou  to  use  in  practice,  because  the  other 
demands  much  time  and  experience.  In  our  practice,  it  is  nearly 
ahvavs  the  second  Axhich  is  emploved.it  is  true,  but  only  because  our 
assistants  or  attendants  relieve  us  of  this  care;  and  if  you  have  in 
the  same  Avav  anvone  -whom  vou  could   train  once  for  all,  use  the 

1.  It  is  done,  for  example  (one  may  say  it  I  think,  without  presemption), 
by  all  the  doctors  at  Berck,  who,  it  is  true,  place  in  it  their  amour-propre 
and  pride  themselves  in  making  good  plasters.  And  they  themselves  profit  by 
it,  as  one  of  the  factors  of  the  apparatus.  The  plasters  of  Berck  are  known 
far  and  Avide.  And  even  at  Paris  it  is  admitted,  that  where  piasters  arc 
concerned,  tlie  apparatus  of  Berck  rank  as  high  as  those  of  Paris. 


8o 


THE    IMMEDIATE    POLISHING    OF    THE    PLASTER    APPARATUS 


second  method  :  if  not,  reserve  it  for  special  occasions,  «  ad  usum 
Delphini  »,  for  a  case  -where  you  are  decided  neither  to  save  time, 
nor  trouble,  to  arrive  at  the  most  beautiful  result  possible.  In  all 
the  other  cases,  you  will  keep  to  the  method  which  follows. 

Immediate  polishing. 

There  are  several  methods  of  performing  this  immediate  polishing. 


Fig.  63.  —  Immediate  polishing,  to  be  done  after  having  rolled  the  last  strip  and 
applied  the  last  layer  of  cream.  The  way  of  doing  it;  over  the  apparatus,  a  large 
square  of  plasterei  muslin  is  applied,  which  is  closely  Ilatlened  and  any  creases 
reduced  hy  pulling  firmly  on  the  sides  which  are  crossed  over  each  other  behind. 

This  is,  after  having  tried  all,  that  which  I  have  found  the  most 
simple,  the  most  practicable  and  the  best  for  you  ;  it  is  to  cover  the 
Avholc  surface  of  the  apparatus  with  a  sheet  of  plastered  mu.slin. 
After  the  application  of  the  last  strip  and  of  the  last  layer  of 
plaster,  you  cut  a  large  square  of  muslin  of  a  single  thickness,  making 
it  of  the  same  length  as  the  apparatus  and  of  a  breadth  a  few  centi- 
metres more  than  the  greatest  circumference  of  the  limb.  You  soak 
it  in  what  remains  of  the  plaster,  or  in  a  new  mixture;  you  smooth 
afterwards  with  the  flat  of  your  hands  the  two  faces  of  this  square, 
well  spread  out,  after  which,  you  will  apply  it  immediately  over  the 
apparatus,  beginning  by  adjusting  the  centre  of  the  square  along  the 


SUBSEQUENT   i'()i.i>ii  1  \( ;   oi-    iiii:   i'i,Asri:u  8i 

nuHliaii.  I1111N1I  I  lie  aiilciior  siirlacr  ol  llic  a|)|iaralu>,  llallciiiiig  il  clow  11 
alloiwaids  and  la\iiii;  tli(>  two  flaps  ol'  llii^  "  niilor  casing  "  upon  tlio 
side  ol  llio  piaster,  up  lo  llic  middle  line  heliind,  wliei-e  \oii  cross  the 
superiluous  portions  ol  tlie  lateral  Haps  over  (nic  anollier.  The  edge 
overlaps  more  or  less  according  as  the  linih  is  more  or  less  thin; 
%\liere  the  overlapping  is  excessive,  where  you  have  too  much  mate- 
rial, lor  example,  at  the  instep,  cut  oil'  the  exuberant  portions  Avith 
the  scissors:  take  care  to  allow  a  I'ew  cenlimctres  I'ni'  the  two  flajis  to 
unite  the  one  with  the  other. 

It  is  all  the  better  to  applv  the  middle  ol'  the  allelic  in  front,  in 
order  that  the  edges  niav  be  thrown  behind,  Avherc  thev  are  not  seen 
(no  little  detail  should  be  disregarded,  seeing  that  we  wish  to  have 
the  apparatus  as  neat  as  possible). 

The  application  of  this  supplementary  sheet  of  plastered  muslin, 
serves,  among  other  things,  to  strengthen  the  plaster'. 

Subsequent  Polishing  of  the  Plaster. 

This  polishing  is  done  about  48  hours  after  the  plaster  has  been 
constructed,  when  it  is  dry.  You  commence  by  softening  the  outer 
plaster  glazing  with  thin  paste;  one,  or  one  and  a  cjuartcr,  cup  of 
water  to  one  cup  of  plaster  of  Paris.  Aou  pass  the  hand  oyer  the 
w  hole  surface  of  the  plaster,  or  you  may  use  a  tampon  soaked  in  this 
Avatery  paste. 

After  two  or  three  minutes,  a  softening  is  produced:  take  advan- 
tage of  this  for  leyelling,  with  a  knife,  the  surface  of  the  plaster, 
clearing  away  all  the  angles  and  ridges,  after  which,  over  this 
carefully  levelled  surface,  vou  spread  a  coating  or  glaze  of  thicker 
plaster,  made  with  two  cups  of  plaster  of  Paris  to  one  cup  of  water. 

The  best  manner  of  proceeding  is  :  —  put  half  a  cup  of  water 
into  a  basin  slightly  inclined  (at  an  angle  of  3o°),  then,  in  the  upper 
part  untouched  by  the  w  ater,  put  in  reserve  a  cup  full  of  plaster  of 
Paris.  Keeping  the  basin  inclined,  take  a  pinch  of  plaster  between 
the  thumb  and  fingers,  dip  the  finger  ends  into  the  water  withdrawing 
them  immediately,  still  holding  the  pinch  of  plaster  which  has 
now  become  a  paste.  This  is  spread  over  a  small  part  of  the  surface 

I.  Keep  lo  tills  method,  and  I  dissuade  you  from  polishing  bv  pasting  on 
the  apparatus  two  great  placards  ol"  dry  muslin  (not  soaked  in  plaster) ;  it  is 
a  dangerous  procedure  for  you  ;  it  hastens  the  setting  of  the  plaster  and,  for 
that  very  reason  i\  ould  not  allow  you  time  for  making  a  good  modelling.  — 
to  say  nothing  of  the  fact  that  this  procedure  in  "  quickening  "'  the  selling 
of  the  plaster,  deprives  it  in  the  end  of  its  firmness. 

Calot.  —  Inclispensahte  orthopedics.  0 


82  ON    THE    USE    OF    PLASTER    IN    FRACTURES 

of  the  apparatus,  in  a  laver  of  about  a  millimetre  in  thickness ; 
afterwards  smooth  over  this  surface  Avith  the  hand  or  Avith  a  tampon 
soaked  in  the  water  which  you  find  in  the  tilted  part  of  the  basin. 
Then,  take  another  pinch  of  plaster  Avhich  you  moisten  in  the  same 
way,  and  cover  another  portion  ;  smooth  it  down  equally  and  so  on, 
until  the  whole  of  the  apparatus  has  been  polished. 

You  get  in  this  Avay  a  glossy  apparatus,  and  the  plaster  after  a  few 
months,  comes  to  resemble  very  fine  old  ivory. 

We  have  often  been  asked  for  the  secret  of  the  composition  of 
the  polish  employed  in  obtaining  the  beautiful  plasters  of  Berck. 
You  see,  there  is  no  secret,  no  mystery ;  the  polish  is  simply  a  layer  of 
plaster  paste,  with  which  —  if  one  has  a  little  practice  and  some  dexte- 
ritv  —  one  can  make  the  most  beautiful  plaster  apparatus  in  the  world  ! 

We  mav  add  that  it  is  easv,  when  the  plaster  is  soiled,  to  recover 
its  Avhiteness.  This  can  be  done  by  passing  over  the  surface  a  tampon 
soaked  with  verv  thin  plaster  (equal  parts  of  plaster  of  Paris  and 
Avaler). 


A   FEW   WORDS    ON    THE    USE    OF    PLASTER 
IN   THE   TREATMENT    OF    FRACTURES 

First.  You  should  apply  your  plaster  immediately,  as  soon  as 
you  see  the  patient,  without  delay,  even  in  the  case  where  the 
limb  is  swollen:    all  vou  have   to  do  Avhen  the  swelling  has  diasp- 


Fig.  C/|.  —  Fracture  of  tibia  with  projecting  fragments;  on  a  level  with  the  fracture 
an  opening  is  made  in  the  plaster  to  compress  the  fragments  (with  squares  of  wad  ind 
kept  in  position  by  a  bandage). 


METHOD    OF    DEALING    \MTII    DISPLACEMENTS  83 

pearcd,  allfr  Icii  or   Iwelve  davs,  is  to  replace  the  lirst  plaster  bv  a 
second  one  more  accurate  '. 

Secondly.      You  must  Ircal  airvour  fraclures,  nol  \\itli  boxsplinls 


Fig.  65.  —  Fracture  of  clavicle  with  displacement.     One  com^iresses  the  projecting 
fragments  through  an  opening  in  the  plaster. 

I.  If,  after  the  twelfth  or  fifteenth  clay,  the  plaster  seems  slightly  slack 
there  is  no  need  to  change  it;  tighten  it  hy  cutting  off  a  strip  from  the  ante- 
rior face  of  the  apparatus  as  descriljed  on  p.    70. 


84 


ox    THE    USE    OF    PLASTER    I.X    FRACTURES 


but  A\itli  circular  plasters,  for  the  reasons  you  already  understand, 
that  -with  a  circular  plaster,  the  patient  Avill  be  at  once  more  comfort- 
able and  better  supported:  you  "will  obtain  the  most  perfect  results. 


Fig.  66.  —  RadiogTam ;  fracture  of 
femur  at  the  lower  third;  angu- 
lar displacement  and  slight  over- 
lapping of  the  fragments. 


y.  6".  —  Reduction  of  the  fracture  has 
been  effected  under  ana?sthesia  ;  radio- 
gram taken  through  an  opening  in  the 
plaster  apparatus :  the  displacement 
remains  as  before  in  spite  of  very 
powerful  traction  exerted  on  the  foot. 


By  constructing  the  circular  plaster  in  the  manner  explained,  by 
inspecting  afterwards  the  condition  of  the  lingers  and  toes,  you  haYe 
no  need  to  fear  for  the  good  nutrition  of  the  plastered  limb. 

a  What  should  be  done  in  the  case  of  a  fracture  complicated 
with  a  wound; 

Make  an  opening  in  the  plaster  (a  few  hours  after  its  construc- 
tion) through  Avhich  to  dress  the  wounds. 


iM.ASTr.K    i\   lUAcii  iu:s    (J|-    Tin.    ll.MI  K 


85 


\[     lliiTc    ;iri'    several    wounds   \oii  can  rosorl 
ion  ol  a  bivalve  plaster. 

//  In  (lio  lasodla  projecting 
fragment,  lor  oxainplo  in  I'rac- 
turc    of    llic     llljia     or    clavicle. 

Exoi'l  pressure  on  I  he  Craii- 
ment;;  ol'  llie  lihia.  or  ol'  the  chi- 
\icle,  with  squares  of  wadding 
lield  bv  strips  of  adiicslve  plas- 
ter. You  exert  pressnro  in  a 
manner  similar  to  that  ol  com- 
pression of  a  Potts'  gibbosity 
Cv.  ch.  V). 

In  the  case  of  fracture,  the 
pressnro  should  be  made  less 
over  the  summit  of  the  projec- 
tion than  upon  the  adjacent  parts 
of  the  bonv  frairments. 


the  conslruc- 


Fracture  of  the  Patella.  — 

Treat  in  the  same  wav.  bv  com- 
pression. Arrange  strips  of  cot- 
ton wool  around  the  t%vo  seg- 
ments of  the  patella.  Proceed 
in  a  similar  manner  in  fractures 
of  the  olecranon. 

Fracture  of  the  Femur.  — 

Here  again,  >ve  make,  rather 
than  the  generally  extolled  ex- 
tension, a  large  plaster,  because 
with  an  accurateplaster  we  obtain 
results  far  superior  to  those 
formerly  obtained  by  Henne- 
quin"s  extension. 

This  plaster  should  be  very 
carefully  moulded  on  the  pelvis: 
before  setting,  one  pushes  against 
the  ischium  from  below  upwards, 
while  vigorous  traction  is  made 
on  the  foot.  Bv  making  an  ope- 
ning in  the  plaster  it  is  possible 


Fig.  68  —  In  this  planter  an  anterior 
opening  has  been  made  opposite  the 
fracture:  this  arrangement  has  allowed 
of  a  progressive  reduction  of  the  dis- 
placement being  effected.  For  some 
consecutive  days,  this  progressive  re- 
duction was  carried  on  by  compresses 
of  wadding,  inwards  on  the  upper 
fragment,  and  outwards  on  the  lower 
fragment  and  renewed  every  three  or 
four  days.  This  radiogram  was  taken 
after  the  removal  of  the  plaster,  six 
weeks  after  tiie  accident.  Compare 
with  it  fig.  60  and  67,  it  can  be  seen- 
that  the  result  obtained  is  perfect. 


to  perfect  the  correction  in  the  way 


86  ORTHOPEDIC    APPARATLS 

here  represented.  Here,  for  example  (tig.  67  et  68)  is  a  case  of  frac- 
ture of  the  lower  third  of  the  thigh,  Avhere  the  radiogram  shows  pro- 
jection of  fragments  which  immediate  reduction,  made  under  chlo- 
roform, Avas  not  able  entirely  to  efface. 

We  made  an  opening  in  the  plaster  at  that  point  and  applied  the 
pads  of  Avadding,  above  and  outwards  at  one  part,  beloAv  and  inwards 
at  the  other,  consequenth"  in  opposite  directions,  to  return  little  b\ 
little  the  two  fragments  into  line. 

This  very  energetic  compression,  Avas  kept  up  by  strips  of  adhesiA-e 
plaster^  and  rencAved  everv  three  or  four  days. 

One  can  see,  by  comparison  of  the  radiograms  (fig.  66,  6']  (a  68), 
all  the  steps  of  the  correction,  and  the  perfection  of  the  result 
ultimately  obtained  by  this  method,  so  simple  and  benign.  Is  there 
another  method  (surgical  operation  or  extension)  AAhich  Avould  give, 
I  do  not  sav  a  better,  but  as  good  a  result?     We  do  not  belicA^e  it. 

For  fractures  of  the  arm  or  fore-arm  one  should  be  guided  by  the 
ame  principles. 


II 


REMOVABLE  APPLIANCES  AND  ORTHOPEDIC 
APPARATUS^ 

Precious  as  plaster  apparatus  are,  thev  do  not  suffice  for  all  our 
needs.      We  shall  see  this    in  studying  each  deformitv. 

But,  by  this  time  aou  Avill  haA-e  found  out  that  for  manv  patients 
the  plaster  apparatus  may  be  contra-indicated,  because  it  is  not  mo- 
vable, noT  articulated ;  and  that  in  some  other  cases,  it  Avill  be  rejected 
simplA'  because  "  it  is  plaster  ". 

I  Avill  explain  myself  : 

First.  In  certain  diseases,  the  patients  require  to  be  supported 
bv  an  apparatus,  but  Avith  the  possibility  of  its  being  taken  off 
from  time  to  time,  in  order  to  folloAv  some  physio-therapeutic  treat- 
ment :  massage,  gymnastics,  bathing,  electricity,  etc. 

Example  :  the  scoliotics  (and  vou  knoAv  they  are  legion). 

Example  :  patients  afflicted  Avith  infantile  paralvsis. 

I.  See,  on  ttiis  subject,  the  admirable  thesis  by  our  assistant  at  Berck, 
Dr,  J.  Fouchet. 


IIIK     IMMCVIIONS     lOH    TIIKSi:    Al'l'AUATUS 


87 


For  some  of  lliesc,  an  apparatus  ma\  l)o  indispensable,  lor  len  or 
Iwentv  Noars,  and  sometimes  I'or  lil'e.  It  cannot  be  a  plasler.  Ijul, 
some  liglil  apparatus,  removable  and  jointed. 

Secondly.  Tliere  arc  oilier  diseases  where  the  treatment  com- 
mences willi  plasler  and  is  terminated  >vitli  removable  apparatus. 


— — ■  -xi-j-  ^' 

Fig.    60.  —  Celluloid  orthopedic  corset,  t-  .    .  .1. 

.,,  .         ^  fiff.   70.  —  A  laro-e  orlhopedic 

with  armature.  ^     '  .        ,,   ,   .  ,      '  ^ 

apparatus  in  celluloid.  —  For 

the    hip    and    entire     lower 

limb. 

Example  :  tuberculous  orthopedic  affections  (Pott's  disease,  hip 
disease,  Avhite  swelling). 

The  plaster  is  Avorn  up  to  the  perioctof  convalescence;  but,  at  this 
moment,  when  the  patients  are  alloAved  to  stand,  it  is  advantageous 
to  replace  the  plaster  by  a  removable  apparatus,  which  fills  in  the 
period  between  that  of  strict  immobility  and  that  of  entire  liberty. 

By  taking  off  the  apparatus  each  night,  and  even  for  a  little  while 


SUPERIORITY    OF    CELLULOID    APPARATUS 


each  day,  the  muscles  are  exercised  and  strengthened,  the  joints  are 
loosened,  gently  and  spontaneously. 

There  are  other  deformities  (such  as  congenital  cluh-Toot,  genu 
A'algum,  tarsalgia)  ^vhere  plaster  is  indicated  immediately  after  the 
correction,  in  order  to  maintain  it  completely. 

But,  after  some  Aveeks  or  even  months,  the  correction  ouoht  to 
he  preserved  hy  a  lighter  apparatus,  Avhich  mav  he  taken  off  at  Avill, 
in  order  to  safe-guard  ^the  nutrition  of  the  muscles  and  the  plav  of 

the  joints. 

Thirdly.  You  Avill  find 
many  patients,  especially 
among  the  upper  classes,  -who 
ought  to  Avear  a  plaster,  hut 
Avho  Avill  not  have  it  at  any 
price,  not  for  a  moment. 

And  Avhy  ?  Simjjly  he- 
cause  it  is  a  plaster,  and 
because  they  are  frightened 
or  rather  humiliated,  by  the 
prospect  of  seeing  their  chil- 
dren immured  for  months, 
perhaps  for  years ,  in  a 
"■"block  of  masonry  ". 

A  leg  plaster,  that  may 
pass;  but  to  be  imprisoned 
in  a  great  "  pillory  "  of  plas- 
ter Avhich  takes  in  the  trunk 
entirely  and  even  also,  the 
head,  that,  never ! 

What  is  to  be  done?  give 
it  up?  No.  One  can  still  at  the  last  extremity  treat  them  and 
cure  them  without  plaster,  by  means  of  movable  apparatus  — 
although  it  involves  a  little  more  trouble  and  more  time. 

Ah!  An  apparatus  Avhich  you  can  remove  Avhen  you  wish  to, 
that,  yes,  they  will  agree  to  that,  or  at  least,  they  will  consent  to  try 
it,  inasmuch  as  celluloid  is  a  more  appreciated  article  than  plaster, 
with  its  bad  reputation. 

They  will  try  the  celluloid,  and,  what  will  happen?  Very  soon 
—  having  become  accustomed  to  it  —  the  patients,  instead  of  being 
tortured,  find  themselves  much  better  with  the  apparatus  than 
without  it,  they  no  longer  Avish  it  to  be  removed,  they  cannot  do 
Avithout  it,  so  that  this  removable  apparatus  becomes,  as  a  matter  of 


^'^S-  7'-  —  Dorsal  aspect  of  the  apparatus 
sliewn  in  fig.  70.  Tlie  two  halves  of 
the  pelvic  portion  are  joined  Ijehincl  by 
two  sliding  pieces  allo^ving  of  the  increase 
of  the  diameter  of  the  girdle. 


(IN    I  III:    I  SE   Of    l'I,A^■llu    loK   c.r.iriAiiN   iiisEAsKS  89 

;kI,   iir('nH)\;iM(' ;   and  so   il   .noes  on    lo   llir  cure:  Iml    Ihcic    was  a 


Fig-.  7^.   —    An    articulated 
Fig.  72.  —  The  same  apparatus  '\>itli  a  >^indo\v  apparatus  in  celluloid  for 

-shutter  opening  allowing  inspection  of  an  tlieliip.     A  bolt  allows  the 

abscess.  joint  to  be  fixed  or  loose 

ned  as  may  be  desired. 

right  Avay  to  render  an  apparatus  acceptable  and  this  Avas,  that  it 
should  not  be  a  plaster  one. 

lou  see  already  how  numerous  are  the  indications  for  removable  appara- 
tus.    Here  are  still  more. 

«.     You    are   consulted  by  a  man  of  very  active   habits,    suffering  with 


Fig.  73.  —  Thanks  to  this  broadpitch  screw  adapted  to  the  femoral  part  of  the  same 
apparatus,  it  is  possible  to  produce  a  certain  amount  of  traction  on  the  limb.  . 


go 


MOVABLE    PLASTER    APPARATUS 


Pott's  disease ;  he  will  not  comprehend  that  he  ought  te  keep  at  rest  in  a  large 
plaster,  or  rather,  cannot,  he  says,  having  a  family  dependent  upon  him. 
He  asks  for  a  movable  corset  which  will  admit  of  his  getting  about  and 
seeing  after  his  affairs. 

b.  Several  times,  I  have  seen  these  patients  with  Pott's  disease"  broken- 
winded  "  and  bronchitic,  asking  for  a  support  which  would  accomodate  the 
thoracic  movements.  I  have  sometimes  supplied,  with  this  object,  a  plaster, 
with  a  very  large  opening,  but  they  prefer  a  moveable  corset.  Also,  through 
especial  anxiety  to  ensure  the  frequent  toilet  of  the  skin, many  ladies  of  fashion 
prefer  celluloid  to  plaster,  etc. 

So  that,  although  plaster  is  always  sufficient  for  the  treatment  of  fractures. 


rig.  75.  —  The  bolt  wliich  Gxes  the  knee-joint  in  extension  for  -walking  and  "which 
the  patient  can  draw  and  unhinge,  In"  means  of  a  cord,  in  order  to  bend  the  knee- 
joint  "when  he  "wishes  to  sit  clown. 

it  may  not  be  possible,  in  the  treatment  of  orthopedic  affections,  to  ignore 
movable  apparatus. 

lou  will  object  that  there  arc  many  patients  unable  to  meet  the  expense 
•of  a  removable  apparatus,  or  to  procure  the  help  of  the  "  assistance  publicpje  "', 
5till  very  defective  in  ovir  country  districts. 

W'hat  can  be  done  for  these  patients? 

One  thing  only  (not  sufficient  for  all  cases,  but  for  most  of  them). 

That  will  be,  whenever  possible,  to  finish  the  treatment  with  a  plaster  as 
in  the  case  of  treatment  of  fractures. 

Come  to  the  w"orst,  it  can  be  done  for  all  deviations  other  than  infantile 
paralysis  (and  it  can  be  done  even  in  certain  cases  of  infantile  paralysis). 

It  can  be  done  in  cases  of  hip  disease,  "n^hite  swelling,  Pott's  disease; 
the  patient  will  be  allowed  to  stand  and  take  his  first  steps  still  wearing  his 
plaster  apparatus.  But  we  will  return  to  this  subject  further  on,  d  propos  of 
these  different  diseases. 


WHAT   WILL   BE  THE   MOVABLE  APPARATUS? 

1 .    Removable  apparatus  in  plaster. 

.  ^^hY  not  make   movable  apparatus  in  plaster,  which  will  have 


SlPEIlIOlti  I  ^     oi"    A     UEMOVAIU.i:     IT.ASTKIl    AI'I'AIIATUS 


9' 


till"  .T<l\;iiilaLr<'  of  clicapriess  and  of  being  constiiicleil  hv  yourselves? 
Hocaiisc  llicv  arc  heavy  and  fragile,  aiul   iiol  capaljlc  of  Ijciii" 


Fig.  76  and  -7.  —  A  celluloid  apparatus  embracing  the  trunk  and  lower  limb  for  co- 
existent Pott's  disease  and  coxitis.  The  limb  portion  may  be  separated,  when 
desired,  from  the  trunk  portion,  Mhich  thus  becomes  an  ordinary  corset. 

articulated.  Therefore,  I  do  not  advise  you  to  make  use  of  them 
in  a  general  way. 

Indeed,  either  the  parents  are  able  to  meet  the  expense  of  the 
celluloid  apparatus  (Avhich  is  much  better  than  the  moveable  plaster), 
or  they  are  not;  then,  it  is  much  better  to  conduct  the  treatment  to 
the  end  with  immovable  plaster,  more  simple  to  make  and  more 
effective  than  movable  ones. 


9^ 


n>FERIORlTY    OF    LEATHER    OR   SILICATE    APPARATUS 


There  remains  however  cases  "where  a  movable  plaster  is  indica- 
ted. We  will  point  out  all  those  different  cases,  as  we  go  along,  a 
propos  of  each  disease.  But  we  may  say,  for  the  present,  that  one 
uses  the  movable  plaster  in  all  cases  of  multiple  fistulce,  or  where 
the  skin  is  verv  irritable  *  and  eczematous,  requiring  daily  dressing, 
or  still  more  in  a  breathless  or  very  nervous  subject,  who  Avishes  to 


Fig.  78.  —   A  large  bivalve  plaster  for  the  lower  limb. 
The   two  valves  will  be  kept  in  position  by  bandages  or  by  straps. 


train  himself  to  wear  his  plaster,  bv  keeping  it  on,  at  the  beginning, 
onlv  a  few  hours  dailv. 

Movable  plasters  are  useful  again  in  certcin  white  swellings  (of 
the  elboAv,  the  wrist  or  the  ankle)  during  the  period  of  injections. 

To  be  effective  and  durable,  the  movable  plaster  should  be 
bivalve. 

But  it  is  not  possible  to  make  it  of  a  single  piece,  that  is  to  say, 
opening  only  in  front,  as  in  a  celluloid  apparatus.  Plaster  is  not  a 
sufficiently  elastic  material  for  that;  made  in  one  piece  only,  it  will 
crack  inside  and  lose  its  form  almost  immediately,  after  having  been 
taken  off  and  replaced  scarcely  four  or  five  firnes. 

I .  In  tliese  two  cases,  the  apparatus  will  be  rapidly  soiled  and  should 
be  renewed  very  often.  It  lAill  therefore  be  much  more  practical  here  to  use 
movable  plasters  than  celluloid,  the  frecjuent  renewal  of  which  would  become 
far  too  expensive. 


ALWAYS    PREFER    THE    APPARATUS    IN    CEF-IA  I.OII) 


93 


The  Bivalve  iMovable  Plaster. 

Mflhtid  "f  ils  coiislruction. 

It  is  sul'licient  to  prepare  an  ordinarv  plaster  in  the  inamicr 
alrcatlv  explained;  and,  when  it  is  dry,  altera  few  hours,  or  belter 
still  alter  a  lew  davs,  it  is  divided  into  two  valves,  by  symmetrical 
incisions  at   the  sides,  or  before  and  behind. 

To  obviate  the  risk  of  damaging  the 
skin  in  dividing  the  plaster,  you  should 
use  two  jersevs  —  or  better,  over  a  single 
jersev.  corresponding  Avitli  two  lines  already 
marked  out  for  two  incisions,  place  bands  of 
wadding  three  or  four  centimetres  Avide  and 
half  a  centimetre  in  thickness  — -  or  better 
si  ill,  two  strips  of  zinc,  such  as  one  uses  in 
moulding  (v.  p.  99). 

The  jersev.  which  remains  attached  to 
the  inner  surface  of  the  apparatus,  serves  as 
a  natural  lining. 

It  is  easY.  afterw  ards,  to  reapply  such  a 
movable  plaster. 

The  two  halves  are  replaced  in  contact  by 
their  edges,  and  kept  so  by  means  of  straps  or 
a  few  turns  of  Velpeau  (if  one  has  to  take  it 
off  every  day),  and  strips  of  sticking  plas- 
ter, (if  taken  off  onlv  now  and  then) ;  or 
again,  one  may  lace  it  with  hooks  stitched  to 
the  strips  of  linen  (fig.  -9)  which  have  been 
fixed  to  the  edges  of  the  apparatus  with  plas- 
ter paste,  or   white  silicate  of  potash,  or  even  with  ordinarv   glue. 

2.  Removable  Apparatus  in  silicate  of  potash  and  leather 
Apparatus. 

I  only  speak  of  these  to  dissuade  you  from  using  them. 

Indeed,  apparatus  in  silicate  arc  too  heavy  and  too  friable. 

As  for  leather  apparatus,  they  are  not  firm  (they  do  not  keep  their 
shape  without  an  armature),  they  are  heavy,  not  clean,  and  are  evil 
smelling. 

3.  Apparatus  in  celluloid. 

Do  you  wish  for  an  apparatus  light,  firm,  clean,  really  neat') 
Then  use  celluloid. 


5.  79.  —  Removable  plas- 
ter corset  ■\vhicli  can  be 
laced  and  unlaced  bv 
nieans  of  books  fixed  on 
tbe  edsres. 


94 


SUPERIORITY    OF    CELLULOID    AP;>AR\TUS 


Fig.    So.    —  The    positive 
mould  (for  coxitis). 


Fig.  8i.  —  The  celluloid  has  beea 
constructed  upon  the  mould ; 
it  has  not  yet  been  removed 
from  the  mould  (v.  fig.  99.) 


Fis.  82 


Method  of  constructing   a  celluloid  apparatus  (for  the  hip).      Squares  of 
muslin  are  spread  upon  the  mould  ^vith  a  brush  dipped  in  celluloid  paste. 


Mirnion  or  constructinc   a  cei.i.i  r.oii)  ai'I'Auati;s 


9» 


('.(•lluldid  liikiiii; more  lliaii  IwciilN-liours  lo  solidil'v,  caniiol  be 
ciHislruclcil,  Jiko  plaster,  on  llie  suljjecl,  who  Avould  have  fiflv  times 
ihe  ehaiiee  ol  h)siiii;  llie  corrcclioii  helorc  ihc  celluloid  became  solid, 
ll  shoidd  be  coustrucled  on  a  mould  (\\g.  86). 

^(Ml  may  prepare  the  celluloid  vourself  if  you  ^visll '. 

Uiir  loiistructs  it  willi  squares  of  niushn  impregnated  willi  cenuloid  paste. 
This  paste  is  made  wilh  acetone  and  llic  debris  ol"  ceUidoid  (about  five  parts 
of  acetone  to  one  of  celluloid). 

Instead  of  using  muslin  strips,  one  uses  scpiares. 


Fig-.  83.  —  Construction  of  the  celluloid  corset.  On  the  positive  mould,  and  covering- 
llie  whole  of  its  anterior  surface,  is  applied  a  square  of  muslin.  (Another  square 
is  applied  afterwards  on  the  posterior  surface). 


The  squares  are  made  of  a  length  equal  to  half  the  circumference  of  the 
mould.  The  first  square  is  applied  in  front,  the  second  behind,  the  third  on 
the  right  side,  the  fourth  on  the  left,  alternately,  so  that  the  celluloid  apparatus 
has  a  thickness  everywhere  of  sixteen  sheets  of  muslin  or  thereabouts.  The 
thickness  ranges  from  8  to  lo  sheets  (for  a  hand  apparatus)  to  20  sheets  (for 
a  large  celluloid  corset  for  an  adult). 

A  brush  is  used  for  applying  the  celluloid.  One  commences  by  applying 
over  the  mould  a  layer  of  oil,  then  a  square  of  muslin  (impregnated  with  the 


I.      As  we  used  to  do  formerly, 
apparatus  in  France. 


Indeed  we  constructed  the  first  celluloid 


96  THE    CONSTRUCTION    OF    AN   APPARATUS    IN    CELLULOID 

paste);  one  pulls  upon  it,  to  adjust  the  edges,  afterwards  a  layer  of  the  cellu- 
loid paste,  then  a  sheet  of  muslin,  and  so  on.  One  lays  on  the  celluloid  and 
the  squares  after  the  manner  of  bill  stickers. 

One  may  construct  the  celluloid  apparatus  in  the  rough  at  [one  sitting  of 
about  half  an  hour;  after  that,  over  the  last  sheet  of  muslin,  two  or  three 
coatings  of  paste  are  laid  on,  repeating  this  every  three  or  four  hours,  until 


Fi^.  84.   —   Tlie  construction  of  a  corset  (continuetl).      By  means  of  a  brush   steeped 
in  the  celluloid  glue,  the  square  is  flattened  down,  at  first  in  the  median  portion 

one  reaches  the  number  of  10  or  13  coats;  this  will  give  the  celluloid  polish 
and  brilliancy. 

After  that,  leave  it  to  dry  for  two  days,  without  touching  it.  Then  the 
celluloid  may  be  taken  off  for  the  fitting. 

To  take  it  off.  one  cuts  along  the  lines,  where,  later  on,  one  will  lace  the 
elluloid  (fig.  81). 

The  fitting  having  been  accompUshcd,  it  is  replaced  on  the  mould;  the 
metal  strengthening  pieces  and  joints,  if  there  are  to  be  any,  are  added. 

^     But,  if  you  have  not  the  aptitude  for  work  of  this  kind,  you  run 


THE     MKTllol)    OF      1  AKINC     A     MolI.D 


97 


llic  rislv  ol  lailiii;^;  in  aii\  ca.-<e,  mucli  lime  and  care  wil  be  required 
of  you,  espcciall\  wlicn  the  apparatus  is  to  have  several  joints.  It  is 
innnitelv  simpler,  more  practical,  andfinallv,  less  costlv,  after  having 
taken  the  mould,  to  :^end  it  to  the  speeial  \\orkers  in  celluloid'. 

Iliev  ^\ill  construct  the  apparatus  and  return  it  to  \ou  if  necessary 
for  a   litlinL;-,   and.    alter   thai    fillini^-  has  been   done    hv   vou  on  the 


B^>'-i-'^4?'Ai}*J^^,B 

F 

■  V     1 

^^^^^^1 

^B^^^^^2 

1 

V  J 

1 

t^^' 

>a^ ^^^t*'" 

►  , 

''^^''-'^H 

Fig.  85    —   The  construction   of  a   corset  (continued).    —  The   edges  of  the    square 
are  coated  over,   while  vou  puU  -\vilh  the  oilier  hand  to  efface  the  creases. 

patient,  who  tlius  need  not  be  disturbed,  they   will  trim  and  finish 
the  celluloid. 

Thus  the  whole  thing  loiU  be  reduced  lo  your  taking  the  mould  and 
filling  the  apparatus,  two  things  very  easily  done,  if  you  proceed  in 
the  followini;  manner  : 

I.     The  Moulding. 

You  have  never  made  one  and  the  very  thouiiht  of  liavinp:  to  take 
a  mould  dismavs  vou.      Verv  well,    be  reassured:    without  having 


I.      Sucli  as  we  have  at  Berck.  in  the  Orthopedic  Institute,  and  as  tliere 
are  no\A"  almost  everv«here  in  France. 

Calot.  —  Tndispensahle  orthopedics.  " 


98 


CELLULOID    APPARATUS 


made  one,  nor  having  even  seen  one  made,  you  will  succeed  at  the 
first  attempt,  for  to  take  a  mould,  it  is  sufficient  to  construct  an  ordi- 
nary plaster  on  the  hare  skin,  and  to  remove  the  plaster  after  it  has 
set;  after  ^vhich,  the  edges  of  the  plaster  are  brought  together,  to 
restore  its  shape,  and  thus  a  perfect  negative  is  obtained . 


Fig.  86.  —  Moulding  of  tlie  instep. 
Cover  the  skin  -witti  an  ordinary 
stocking  cut  off  at  the  toes  to  allow 
a  strip  of  zinc  being  inserted  bet- 
ween the  skin  and  the  stocking 
over  which  the  mould  may  be 
cut,  in  order  to  remove  it. 


Fig.  87.  —  Placing  the  attelles  for  the 
moulding  of  the  instep,  lou  com- 
mence by  applying  squares  of  plas- 
tered muslin.  Over  these  you  roll  a 
plastered  strip. 


The  position  in  Avhich  the  patient  is  placed  for  moulding  is,  as  a 
general  rule,  the  same  as  that  adopted  in  constructing  a  plaster  appa- 
ratus for  the  same  region. 

For  the  lower  limbs  (foot,  leg,  hip),  it  should  be  the  horizontal 
position  ;  for  the  trutdv,  the  vertical  position. 

The  patient  touching  the  ground  completely  with  the  feet  and 
lightly  supported  (I  do  not  say  suspended,  but  supported)  by  the 
head,  by  means  of  the,  today,  classical  strap  (fig.  248  and  following). 
—  For  the  upper  limb,  the  upright  position. 


MKIIIOI)   <)l"    takim;    a    molld 


99 


Fig.  88.  —  Moulding  of  the  knee  :  the  leg  is  covered  with   the  sleeve  of  a  jersev, 
underneath  ■which  has  been  passed  a  strip  of  zinc  about  three  centimetres  wide. 

ButAvc  Avill  now  go  into  details,    There  are  two  precautions  lo  take. 
I .     In  order  that  the  plaster  may  not  adhere  to  the  skin  and  to  the 


Fig.  i>9.  —  The  position  of  the  two  strip - 
in  moulding  the  lower  part  of  the 
trunk  and  lower  limb  (for  a  small 
celluloid  apparatus  in  hip  disease). 


lig.  go.  —    ^loukling  of  the  trunk.     How 
to  place  the  strips  beneath  the  jersey. 


lOO  CELLULOID  APPARATUS 

hair,  a  thin  but  continuous  layer  of  vaseline  is  applied  over  the  whole 
of  the  region  to  be  moulded. 

You  Avill  find  in  a  toAvn  Clinic  many  timorous  parents  of  children 
Avho  dread  the  contact  of  plaster  with  the  bare  skin.  For  these  you 
should  make  a  mould  over  a  closely  fitting  casing  (a  jersey,  a  sock,  a 
stocking).  This  fabric  makes  a  protective  lining  to  the  inner  surface 
of  the  mould,  and  comes  off"  with  it.  So  that  the  adhesion  of  the 
covering  Avith  the  plaster  may  be  more  intimate,  you  commence  by 


Fig.   91.    —  Cutting  a  mould  for  the  knee. 
You  cut  over  the  zinc  strips  so  as  not  to  -wound  the  patient. 

spreading  over  the  outer  surface  of  the  covering,  a  layer  of  plaster 
cream  before  applying  the  plastered  attelles  and  strips. 

2.  To  prevent  all  risk  of  wounding  the  patient  in  removing  the 
mould,  you  place  immediately  over  the  skin  one  or  several  strips  of 
zinc  three  or  four  centimetres  wide,  upon  which  you  can  cut  the 
mould  afterwards,  as  upon  a  director. 

The  strips  being  placed  in  position,  you  have  only  to  construct  the 
plaster. 

You  do  this  with  attelles  and  strips  of  muslin,  after  the  manner 
of  an  ordinary  plaster.  You  may  introduce  some  slight  variations 
meanwhile,  thus; 

a.  Begin  the  apparatus  by  the  application  of  squares  or  attelles, 
and  finish  with  plastered  strips. 


PKACTICAI.    TI'CIIMOIE    01'     \l(»l  f.DlNC 


lOI 


6.      ']"(i  liasU'ii  llic   (lixiii-    of   llio   |)l;i>|cr,  lli;ii    is  lo  say,  lo  save 
time,  \ou  ma\  here  use  tepid  waler,  al  'A'y'  or  /|0",  or  even  cold  water 


Fig-  92.    —   Cullitig   a  mould  of  tiie  tliigli. 

uitli  salt  (tMO  or  three  tea-spoonfuls  of  salt  in  each  of  the  t-wo  basins 
in  Axhicli  are  the  attelles  and  strips). 


Fig.  f)3.  —  Cutting  a  mould  of        Fig.  g/,.  _  The  mould  having  been  removed,  tlie 
the  trunk.  edges  are    approximated  and   held   in  contact 

by  several  turns  of  soft  muslin  bandage. 


102  CELLULOID  APPARATUS 

This  premature  drying  would  have  some  drawbacks  to  the  firm- 
ness of  an  ordinary  plaster  which  has  to  be  kept  on  for  a  certain 
time ;  it  has  none  here,  for  a  mould  intended  to  be  done  away  with 
after  a  few  hours,  when  it  has  served  as  a  mould  or  mannequin. 

It  goes  without  saying  that  as  soon  as  you  have  applied  the  strips 
and  attelles,  before  the  plaster  has   set,    you   verify  the   position 


Fig.  95.  Fig.  9O. 

Fig.  g5.  —  A  negative  mould  (of  the  trunk)  placed  upon   a  bench  in   readiness  for 

the  pouring   in  of  the   plaster  cream,  that  is  to   say,  for  the    preparation  of  the 

positive  (see  follo-\ving  figure). 

Fig.  96.   —  The  positive  mould    obtained   from   and    taken   off  the  negative   mould 

of  the  preceding  figure. 

of  the  region  to  be  moulded  and  you  model  the  articular  or  periarti- 
cular prominences.     You  model  as  well  the  edges  of  the  zinc  strips. 

Immediately  after  the  setting  of  the  plaster  (or  some  minutes 
after)  you  remove  the  mould  by  cutting  with  a  bistoury  or  an  ordi- 
nary knife  over  the  zinc  lathe,  and  right  down  to  it,  that  is  to  say, 
you  cut  also  the  jersey;  you  then  raise  the  edges  of  the  mould  and, 
thanks  to  the  presence  of  vaseline,  or  of  the  jersey,  the  mould  detaches 
itself  easily  from  the  skin,  without  any  tugging  painful  to  the 
patient. 

One  proceeds  with  the  removal  gently  and  cautiously,  so  as  not 
to  crack  the  apparatus. 


Ill  IING    THE    AIM'AHATIS 


io3 


One  IIhmi  biings  together  the  edges  and  one  keeps  llioni  in  coiil;iti 
cither  with  an  attollo  of  plastered  nuislin  whicli,  encroaching  on  the 
two  edges,  will  serve  as  a  '*  clasp  ",  or  Avith  a  band  oC  soil  muslin 
rolled  round  the  entire  mould. 

In   order  to  construct  the  "  positive  "  one  has  only  to  pour  into 


^'e-  97-  —  The  celluloid  corset  finished.  '  When  it  is  dry,  cut  it  along  the  mediaa 
anterior  line  and  above  each  shoulder,^in  order  to  remove  it  and  (o  carry  out 
the  fitting  on  the  patient. 

this  hollow  mould  some  plaster  cream  ^  But  you  may  avoid  this 
trouble,  by  employing  a  worker  in  celluloid;  send  him  the  neo-ative 
mould,  such  as  it  is,  and  he  will  reproduce  the  "  mannequin  " 
upon  which  he  will  construct  the  celluloid  apparatus. 

At  the  end  of  a  few  days,  as  I  have  already  said,  he  will  be  able 
to  send   you  the  celluloid  so  that  you  may  fit  it  upon  your  patient. 


I.  I  refer  you,  for  all  the  details,   to  the  thesis  already  mentioned  of  my 
assistant,  D'  Fouchet. 


I04  CELLULOID   APPARATUS 

The  fitting  of  the  celluloid  apparatus. 

Utility  of  fitting.  —  ^ou  mav  think  that  the  celkiloid,  having 
been  constructed  on  a  faithful  mould,  does  not  need  to  be  fitted ; 
nevertheless  I  advise  you  to  make  such  fitting  whenever  it  may  be 
practically  possible. 

It  will  afford  you  an  opportunity  of  correcting,  Avith  absolute 
precision,  the  length  and  breadth  of  the  apparatus,  the  level  of  the 
lines  of  the  joints,  the  situation  of  anv  openings  and  hollows,  etc. 

Thanks  to  such  fitting,  you  Avill  be  able  to  obtain,  still  more 
certainly,  a  perfect  apparatus,  that  is  to  sav,  without  causing  any 
discomfort  to  the  patient,  and  thoroughlv  fulfilling  its  object. 

Fitting  the  apparatus  for  the  foot. 

The  celluloid  is  sent  to  vou  (bv  the  constructor)  in  two  pieces,  one 
for  the  foot,  the  other  for  the  leg,  which  are  divided  on  a  level  with 
the  line  of  the  tibio-tarsal  articulation,  or  rather  a  little  below  it,  on 
a  level  with  the  axis  of  movement  of  that  articulation.  Without  this 
divisionit  wouldbe  very  difficult  to  apply  the  apparatus  round  theinstep. 

It  goes  Avithout  saying,  that  each  piece  has  been  split  along  the 
anterior  median  line  where  the  finished  apparatus  will  be  laced. 

The  fitting  is  done  upon  the  skin,  bare,  or  covered  with  a  sock  or 
very  thin  stocking. 

The  two  pieces  of  celluloid  are  placed  in  position  in  turn,  pulling 
them  firmly  ajar  in  front  (this  mav  be  done  without  cracking, 
thanks  to  the  elasticity  of  the  celluloid). 

Notice  that  the  anoles  of  the  celluloid,  not  vet  trimmed,  are 
almost  sharp,  and  to  prevent  them  pinching  or  lacerating  the  patient's 
skin,  when  the  apparatus  is  put  on,  you  should  take  care  to  take 
these  angles  betAveen  your  fingers,  calling  in  the  help,  if  need  be, 
of  one  or  tAvo  bystanders. 

Verify  the  upper  and  loAver  ends  of  the  apparatus,  and  especially 
the  AAadth  of  each  piece.  If  thev  are  a  little  too  Avide,  let  your  assis- 
tant make  the  tAvo  sides  overlap  one  another,  and  chalk  out  froin 
top  to  bottom,  the  line  of  crossing  of  the  edges,  that  is  to  say,  the 
limits  of  the  small  strips  of  celluloid  to  be  removed. 

If  the  tAvo  pieces  are  a  little  too  narroAv,  you  mark,  in  the  same 
Avay,  the  distance  Avhich  separates  the  tAvo  edges,  so  that  the  maker 
may  increase,  by  so  much,  the  Avidth  of  the  fore  piece,  Avith  a  flap 
of  soft  leather  added  to  it.  One  does  not  leave,  in  fact,  the  rigid 
anterior  part  of  the  celluloid,  Avhich  Avould  make  it  difficult  to  take 
off  and  put  on  the  apparatus.  One  replaces  it  by  tAvo  strips  of  soft 
leather  Avith  evelets. 


FITTING    THE    CEIXULOIO 


io5 


The  loo(  iiiul  \v'j;  being  covonHl  willi  lliclr  sIkmIIi  oT  celluloid,  see 
that  llie  ])roiniiietices  of  the  malleoli  correspond  well  Asilli  llie  depres- 
sion in  llie  celluloid.  This  Avill  salisly  \ou  ihal  the  metallic  joints 
are  avcU  on  a  level  witli  the  natural  articulations  and  that  the  pieces 
of  steel  will  not  exert  any  abnormal  pressure  on  the  bony  promi- 
nences. 

You  can  afterwards  mark  llie  limits  of  llio  hollow  iiip  at  (he  instep, 


Fig.  g8.  —  Fitting  an  apparatus  to  tlie  foot  :  tlie  leg  portion   and  tlie  foot  portion 
have  been  divided  opposite  the  tibio-tarsal  articulation  and  split  in  front. 


Avhicli  liollo>ving  varies  Avith  the  degree  of  flexion  you  wish  to  have. 
But  vou  mav  be  able  moreover  to  dispense  with  that,  for  Avith  your 
Avritten  instructions,  the  maker  will  be  able  to  give  the  apparatus 
the  amount  of  play  desired. 

For  the  rest,  in  a  general  wav,  restrict  vourself  to  tracing  with 
chalk  the  slight  modifications  w  hich  appear  to  you  necessary,  w  ithout 
cutting  anvthing  off  yourself.  The  maker  is  furnished  with  tools 
to  execute    more  easily    and    neatly    the    alterations   you    require. 

He  supplies  afterwards  the  apparatus  with  its  articulations,  the 
disposition  of  Avhich  Avill  enable  you  to  leave  them  rigid  or  loose 
according  to  vour  likino;. 


io6 


CELLULOID    APPARATUS 


But   you   will  apply  the  celluloid  to   the  patient  yourself,  and 
superintend  its  use. 

Fitting  an  apparatus  for  the  leg. 

In  the  same  Avay,  when  fitting  on  an  apparatus  for  the  leg,  it  is 
necessary  to  make  certain  that  the  depressions  of  the  appai^atus  cor- 
respond Avell  Avith  the  particular  pi-omi- 
nences  of  the  region ;  to  A'Ci'ify  also  the 
length  and  width,  and  to  mark  with  a 
pencil,  the  level  of  the  line  of  the  knee- 
joint  (the  line  which  corresponds  to  a 
horizontal  passing  through  the  point  of  the 
jjatella);  and,  finally,  you  should  mark  on 
the  celluloid,  on  a  level  with  the  popliteal 
sjDace,  the  large  piece  to  he  hollowed  out  on 
the  two  leg  and  thigh  pieces  of  the  cellu- 
loid in  order  to  permit  the  movements  of 
flexion  of  the  knee,  in  cases  where  you 
wish  to  preserve  those  movements.  But, 
as  in  the  apparatus  for  the  foot,  you  may 
dispense  with  that ;  the  maker  should  easily 
know,  with  your  written  instructions,  how 
to  make  the  posterior  hollows  and  give  the 
articular  play  required. 


Fig.  99.  — A  small  cellul- 
oid for  hip-disease  ope- 
ned and  separated  from 
Ihe  mould.      It  is  ready 

for    FITTING. 


Pitting  a  celluloid  for  the  hip  and  one 
for  the  entire  lower  limb. 


The   constructor    sends    you    this   large 

celluloid  in   four  segments  ;   pelvis,   thigh, 

leg  and  foot,  Avhich  facilitates  greatly  the  fitting.     When  the  hip  or 

the  knee  ought  to  remain  rigid,  he  sends  you  three  segments  only. 

The  small  celluloid  for  the  hip  is  in  one  piece  only. 

See  fig.  100  for  the  method  of  putting  on  the  apparatus. 

You  commence  hy  placing  in  position  the  pelvic  segment,  the 
girdle;  then  you  put  on  the  femoral  segment.  In  order  not  to  injure 
the  patient  in  doing  this,  cover  the  angles  Avith  cotton  avooI  or  Avith 
your  fingers.  The  edges  are  kept  in  contact  either  with  your  hands,  or 
with  straps  encircling  the  pelvis  and  the  two  seginents  of  the  celluloid. 

You  make  certain,  here  again,  that  the  depressions  in  the  appa- 
ratus correspond  Avith  the  prominences  of  the  region.  You  verify 
the  length  and  Avidth  of  the  celluloid. 

The  thigh   of  the  opposite  side  should  be  able   to  be  flexed  to 


FiiriNr;    i  iir  celluloid 


107 


about  an  angle  of  90";  il  is  ncccssarv  lo  remember  lliat,  in  order' lo 
hollow,  if  need  be,  the  apparatus  at  this  point.  More  than  that,  if 
it  is  desired  to  put  on   lliis  (tlie  sound)  side  a  strap  of  leather  or  soft 


Fig.  100.  —  Fitting  an  apparatus  for  the  hip.  The  manner  ol  putting  it  on  when 
one  is  alone.  First,  open  and  introduce  the  pelvic  segment,  then  the  femoral. 
If  you  have  an  assistant,  you  can,  wilh  his  help,  open  and  introduce  the  two  seg- 
ments at  the  same  time. 

tissue  (to  prevent  the  celluloid  from  rocking)  you  should  indicate  the 
points  of  attachment  and  the  length  and  breadth  of  the  strap. 
Lastly,  the  upper  edge  of  the  apparatus,  in  front,  over  the  abdomen, 
is  cut  in  the  form  of  a  crescent,  in  such  a  Avav  that  the  middle  por- 
tion leaves  the  umbilicus  uncovered. 

^^  e  Avill  describe,  in  the  chapter  on  Pott's  disease,  the  method  of 
fitting  on  the  celluloid  corset  (v.  p.  827). 


CHAPTER  II 


A  WORD  ON  AN>ESTHESIA  IN  ORTHOPEDICS 


I.  -  LOCAL  AN/ESTHESIA 

a.  Cocain  and  Stovain  are  not  often  used  in  Orthopedics. 
Tliey  may  be  used,  of  course,  to  perform  a  tenotomy,  when 
this  tenotomy  is  the  only  interference  required  ;  this  is  very 
rare ;  but  in  torlicolhs,  in  congenital  club-foot,  in  old  hip- 
disease,  division  of  the  tendon  is  not  the  only  factor  in  the 
correction,  and  vigorous  movements  for  redressment  are  indis- 
pensable before  and  after  the  tenotomy.  These  manoeuvres  nearly 
always  require  general  anaesthesia. 

h.  Ethyl  chloride  as  spray  is  the  ordinary  local  aneesthetic 
for  puncture  of  an  abscess  and   for  intra- articular    injections 

(v.  fig.    Ill,   p.    l32). 

This  anaesthetic  is  sufficient,  provided  that  it  is  used  with 
care;  one  waits,  to  introduce  the  needle,  until  the  skin  is 
blanched  over  an  area  the  size  of  a  five  shilling  piece.  Old 
patients,  always  ask  for  «   a  little  more  ethyl  chloride   ». 

But  avoid  the  direct  and  prolonged  contact  of  ethyl  chlor- 
ide with  integument  which  is  already  reddened  and  thin, 
the  vitality  of  which  is  very  low,  as  the  chloride  might  reduce 
it  still  more.  In  that  case  produce  the  anaesthesia  on  the 
sound  skin,  some  distance  away,  and  there  you  will  puncture. 


SOME    REMARKS    O.N     (iENEUAL    AN.ESTHESIA  109 

II.  —  GENERAL  AN/ESTHESIA 

This  may  be  pioduced  by  chloroform,  or  b\  ether'. 

If  vou  are  accustomed  to  ether,  you  slioukl  keep  to  it;  if 
mil.  I  advise  \ou  lo  prefer  chloroform.  Ether  is,  it  is  true,  a 
little  more  easy  to  administer  than  chloroform;  but  it  exposes 
the  patient  to  grave  inllammalion  of  the  air-passages,  Avhicb 
mav  lead  to  pulmonary  gangrene  and  abscess  of  the  lung,  and 
more  than  that,  during  the  whole  of  the  antestliesia,  etiier 
keeps  the  patient  in  a  state  of  manifest  asphyxia  which  some- 
times becomes  alarming. 

Therefore,  you  should  employ  chloroform  by  preference.' 
There  are  two  remarks  to  be  made  on  its  use  in   orthopedics. 

a.  The  first  is  that  chloroform  as  a  general  rule,  is  much 
better  tolerated  by  children  than  by  adults,  who  are 
nearly  always  more  or  less  out  of  condition,  or  are  alcoholic, 
atheromatous,  emphysematous,  etc. 

h.  The  second  is  that,  in  orthopedics,  anaesthesia  does  not 
need,  in  an  ordinary  way,  to  be  pushed  to  its  extreme  limit, 
for  example,  as  far  as  in  abdominal  surgery,  where  it  is  neces- 
sary to  aAoid  the  least  reflex  moyements  of  the  intestines.  — 
So,  for  the  correction  of  a  congenital  luxation,  a  coxitis,  or  for 
a  club-foot,  it  is  sufficient  that  the  patient  is  insensible  to  pain 
and  unable  to  make  any  movement  of  a  nature  likely  to  hinder 
the  operator;  in  other  Avords  it  is  sufficient  that  the  muscular 
resistance  is  overcome  and  that  the  patient  does  not  cry  out. 
You  may  then,  in  orthopedics,  be  satisfied  very  often  with 
an  anaesthesia  such  as  you  would  use  to  reduce  a  traumatic 
dislocation  of  the  shoulder  or  perform  taxis  in  a  case  of  hernia. 

Now,  here  are  some  indispensable  notions  on  chloroformisa- 
tion .  I  think  it  is  not  a  digression  to  give  them  here,  because  they 
are  too  often  violated  or  misunderstood,  and  they  do  not  appear 
to  me  to  be  clearly  set  forth  in  the  large  treatises  on  surger\ . 

I.  I  do  not  see  an\  advantage  etlivl-ljroinide  has  over  cliloroforni,  and  I 
mvself  use  the  latter  even  for  the  removal  of  adenoid  vegetations. 


no      GENERAL    ANAESTHESIA.    PREFERENCE    OF    CHLOROFORM 


The  absolute  criterion,  the  only  one,  to  know  if  the  sub- 
ject —  Infant  or  adult  —  put  under  chloroform,  sleeps  suffi- 
ciently, but  not  too  profoundly,  is  to  see  that  his  corneal 
reflex  is  retained.  It  is  necessary,  during  the  whole  operation, 
that  the  reflex  he  preserved,  whilst  the  general  sensibility  and  the 
resistance  of  the  muscles  of  the  limbs  are  abolished. 


Fig.    101.    —    llie  ocular  reflex.   —  First  stage;    the  an2Bsthetist  has   partly  opened 
the  eyelids  of  the  patient  and  placed  the  tip  of  his  index  finger  on  the  eye. 

By  the  corneal  reflex,  one  means  the  contraction,  active  and 
immediate,  of  the  eyelids  (always  appreciable  in  the  upper 
eyelid),  Avhen  it  is  left  free,  after  having  been  stimulated  by 
touching  the  cornea  of  the  patient  with  the  index  fmger  (fig.  loi 
and  102).  If  the  patient  is  insensible  and  inert,  at  the  same 
time  that  the  contractility  of  the  eyelids  persists,  the  anaes- 
thesia is  sufficient  for  what  is  to  be  done;  orthopedic  correc- 
tions, and  surgical  operations. 

Ancesthesia  has  then  been  sufliciently   «   pushed  ». 

One  is  certain  that  it  is  not  too  much  so,  as  long  as  the 
corneal  reflex  remains.     Security  is  then  complete. 


THE    ONLY    CERTAIN    CRITERION;    Till-    COKNEAL    REFLEX         III 


During  tlie  whole  of  llic  opcralion,  do  nol  exceed  this 
degree  either  on  this  side  or  on  tlial,  Ijiit  preserve  it  hy  a  few 
drops  ol"  clilorolorm  athiiinistered  from   lime  lo  time. 

When  the  patient  has  lost  the  corneal  rcfle.c,  one  does  not 
know  where  one  is,  and  it  may  he  one  has  gone  too  far. 

Apart  from  tlie  corneal  reflex,  no  sign  is  of  absohifc  value. 


Fig.    102 

Tlie  eve 


.  —  The  ocular   reflex.  —  Second  stage  [:   anx-thetist,   after  having  touched 
the  cornea,  quickly  removes  his  hand  to  allow  the  eyelid  to  close, 
ought  to  close  firmly,    in    an  active  fashion,  which   can  be  recognised  by  the 
folds  which  are  formed  at  the  commissure. 


The  respiration,  the  pulse,  the  color  of  the  face,  the  dilata- 
tion and  contraction  of  the  pupil,  do  not  signify  very  much. 
The  respiration  may  even  remain  perfect,  the  pulse  normal, 
the  face  of  a  rosy  colour,  the  pupil  contracted,  and  everything, 
in  a  word,  may  appear  up  to  that  point  satisfactory,  Avhen 
suddenly,  without  any  warning,  the  respiration  and  the  pulse 
stop,  and  then,  it  may  be  too  late. 

Rely  then  entirely  on  the  corneal  reflex;  it  alone  will  not 
deceive  you. 

The  talent  of  the  ansesthetist   consists  precisely  in  attaining 


112  CE\ERA.L    ANESTHESIA.    ITS    TECHNIQUE 

this  condition,  and  in  keeping  constantly  to  this  degree  of  anaes- 
thesia, to  take  care  on  the  one  part,  not  to  allow  the  patient 
to  awaken,  which  is  evidenced  by  the  movements  of  defence 
of  his  limbs  or  by  his  complaining ;  to  prevent  on  the  other, 
narcosis  becoming  too  profound,  which  is  ascertained  by  the 
loss  of  the  ocular  reflex. 

In  the  first  case,  if  the  patient  makes  some  movements ''of 
defence  (still  being  unconscious),  give  him  six  or  eight  'drops 
of  chloroform  every  eight  or  ten  respirations  (do  not  hurry, 
do  not  give  the  chloroform  in  large  quantity  at  this  moment) 
until  again  he  is  motionless. 

In  the  second  case,  when  the  ocular  reflex  has  been  lost, 
stop,  do  not  give  any  more  chloroform  until  the  reflex  has 
reappeared  :  —  and  so  on,  until  the  end  of  the  chloroformisation. 

1.  The  ordinary  method  of  producing  sleep.  For  child- 
ren who  understand,  above  lo  years  of  age,  proceed  gradually 
by  slight  and  continuous  closes  as  you  would  do  for  an  adult. 

Every  six  or  eight  respirations,  throw  six  or  eight  drops 
of  chloroform  upon  the  outer  surface  of  the  mask,  turning  it 
quickly  over  upon  the  child's  face. 

2.  The    method    of   producing  sleep  instantly.      If  the 

child  is  very  small,  or  very  nervous,  if  fear  and  alarm  causes 
him  to  cry  and  struggle  violently  at  your  approach,  if  he 
resents  all  your  coaxing,  if  he  will  not  be  soothed  nor  listen 
to  anything,  it  is  better  for  him  that  you  proceed  expeditiously 
and  put  him  to  sleep  quickly. 

Whilst  his  hands  and  feet  are  held,  quickly  throw  fifteen 
or  twenty  drops  of  chloroform  upon  the  mask  and  apply  it 
quite  closely  to  his  face,  without  allowing  the  admission  of 
any  pure  air.  His  cries  Avill  at  once  cease ;  the  child  struggles 
for  scarcely  six  or  eight  seconds ;  he  quickly  loses  all  knoAv- 
ledge  of  his  surroundings.  You  keep  the  mask  in  position 
for   ten  or  fifteen   seconds    only.     The   child's  face  is  a  little 


INSTANTANEOUS    NAUCOSlS    IN    ClIir.DHOoi) 


ii3 


ooii^oslc'il,  l)ul  il  is  already  molionlcss,  having  iiOAvcver  the 
ocular  rcllex  slill  plainly  marked. 

You  proceed  from  lliis  moment  very  gently,  Avlth  six  or 
eight  drops  every  six  or  eight  respirations,  the  face  regaining 
its  rosy  hue  in  a  few  seconds. 

Tf  the  first  whifs  of  chloroform  have  not  heen  sufficient  lo 


Fig.  io3.  —  Withdrawing  the  tongue  ;  with  the  left  hand  the  tongue  is  drawn  out 
of  the  mouth ;  the  index  finger  of  the  right  hand  firmly  turning  out  the  labial 
commissure  from  the  dental  arches. 

abolish  the  defensive  movements  in  a  child  of  six  or  seven 
years,  for  example,  give  a  second  dose,  proceeding  as  Jias 
been  already  explained. 

During  narcosis  ahvays  take  care  to  support  the  patient's 
chin  with  your  fingers;  that  facilitates  the  respiration  greatly. 
If  he  vomit,  it  is  because  he  is  awakening.  Give  him  another 
dose  of  chloroform,  slowly,  Avithout  too  much  hurry;  thai 
would  be  dangerous. 

If  respiration  has  ceased  (but  that  will  not  occur  until 
the    ocular    reflex    has    been  lost,    which    will    not    occur   if 

Calot.  —  Indispensable  orthopedics.  8 


I  1 4  CHLOROFORMIS ATION 

carefully  Avatched)  one  should  immediately  AA'ithdraAV  the 
child's  tongue  Avith  special  forceps,  or,  in  default  of  them, 
with  a  safety-pin,  keeping-  it  outside  by  exerting  slight  traction 
on  one  side,  the  head  being  turned  and  laid  on  that  side, 
whilst,  with  a  finger  introduced  into  the  mouth  between  the 
teeth  and  the  opposite  cheek,  the  cheek  is  raised  (fig.  io3). 

This  manoeuvre  of  AvithdraAA-ing  the  tongue  and  raising  the 
cheek  suffices  nearly  ahAays  to  restore  the  breathing. 

If  it  does  not  suffice,  perform  artificial  respiration.  Re- 
member that  in  such  a  case  it  is  the  only  thing  to  be  done 
and  do  not  lose  time  in  doing  anything  else.  The  anaesthe- 
tist supports  the  head,  not  too  much  flexed,  nor  too  extended, 
on  the  table  :  toalloAA"  it  to  hang  over  the  table,  as  advised  by 
some  authors,  is  bad;  it  might  produce  too  great  tension, 
and  consequently  a  partial  closure  of  the  air  passages.  An 
assistant  holds  the  legs  as  a  counter-resistance  to  the  traction 
Avhich  you  yourself  make  on  the  upper  part  of  the  trunk,  in 
manoeuvering  the  arms  to  produce  artificial  respiration  :  but 
I  need  not  insist  on  that  —  you  know  all  about  it.  The  ma- 
nceuvres  of  artificial  respiration  are  studied  and  illustrated  in 
all  the  treatises  on  minor  or  major  surgery. 

I  Avish  to  conclude  Avith  tAvo  observations  : 

a)  \Mien  you  are  about  to  redress  a  case,  you  should  not 
alloAv  the  patient  to  awaken  until  the  proceeding  is  quite 
finished  and  the  plaster  «  set  ».  Allow  the  patient  to  aAvaken 
gently. 

b)  Lastly,  I  Avish  to  point  out  that  Avhen  the  patient  is 
ready  to  aAvaken,  he  appears  sometimes  to  haA^e  lost  his  ocular 
reflex  and  his  respiration  become  all  at  once  silent.  Do  not 
be  alarmed;  press  a  little  harder  on  the  cornea,  and  you  AA-ill 
see  the  eyelid  react ;  moreover,  the  complexion  instead  of  being- 
pale,  is  here  as  rosy  as  that  of  a  person  sleeping  naturally. 


CHAPTER   III 

THE  TECHNIQUE  OF  PUNCTURES  AND  INJECTIONS 

I 

IN  THE  TUBERCULOUS  SUPPURATIONS 

Take  note  from  the  beginning  that  this  technique  is  the  same  for  all 
tuberculous  suppurations,  equally  well  hip-disease  and  Pott's  disease  as  cold 
idiopathic  abscesses. 

SUMMARY   OF    THE  [TECHNIQUE K 

A.  What  it  is  necessary  to  obtain. 

1°  As  to  instruments  :  a  needle,  number  3.  a  small  aspirator,  a  glass 
syringe  (all  these  instruments  should  be  capable  of  being  boiled). 

2°  As  to  modifying  liquids  :  2  flasks,  one  of  oil,  cresote,  and  iodo- 
form   toil   70   grammes,   ether  3o   grammes,  creosote    5    grammes,    gaiaco! 

1  gramme,  iodoform  10  grammes). 

The  other  of  naphthol   camphor  with   glycerin    (naphtol  camphor 

2  grammes,  glycerin  12  grammes);  this  second  mixture  should  be  shaken 
vigorously  for  a  minute  and  a  half  and  injected  immediately,  because  it  is 
very  unstable. 

These  two  liqvxids  are  all  that  are  required. 

The  indications  for  each  :  As  a  general  rule,  inject  the  first  of  them 
(the  oil).  —  lou  may  reserve  the  second  (naphthol  camphor)  for  the  case 
where  an  abscess  contains  clots  blocking  the  needle,  in  which  case  two  or 
three  injections  of  naphthol  camphor  will  soften  and  dissolve  the  clots ;  after 
M'hich,  you  return  to  the  first  liquid. 

The  dose  to  inject  is  the  same  for  the  Uvo  liquids,  namely;  2  to 
12  grammes,  according  to  the  age  of  the  patient,  for  abscesses  of  a  capacity 
of  20  cm.  c.  and  more. 

If  the  abscess  is  very  small,  less  than  20  cm.  c.  you  inject  half  as  much 
liquid  as  of  the  pus  withdrawn.  In  this  way  all  h^per-tension  of  the  skin  is 
avoided. 

3°  Have  also:  a)  a  tube  of  ethyl  chloride  for  local  anaesthesia  and  some 

I.  If  you  are  pressed,  for  time,  content  yourself  with  reading  this 
summary  where  are  collected  all  the  leading  ideas  —  returning  later  to  the 
reading:  of  tlie  entire  chapter. 


]l6  PICTURES    AJJD    INJECTIONS   IN    THE    TUBERCULOSES 

tincture  of  iodine  for  sterilization  of  the  skin;  b)  a  small  boiled  cup,  to  contain 
and  take  from,  the  liquid  to  be  injected;  c)  and,  lastly  a  sterilized  dressing. 

B.     The  Technique. 

When  should  you  commence  the  punctures? 

Immediately  the  abscess  is  plainly  perceptible,  provided  you  can  get  at  it 
without  danger.  (But,  this  danger  only  exists  for  deep  abscesses  in  the 
iliac  fossa;  here,  you  may  postpone  the  puncture  until  the  abscess  has 
become  easily  accessible). 

For  this  technique,  there  are  two  recommendations;  be  very  clean  and 
use  fine  needles  only. 

a.  To  be  very  clean;  be  quite  sure  of  the  asepsis  of  your  hands,  of 
the  patient's  skin,  of  the  instruments,  of  the  liquids  to  be  injected,  of  the 
after  dressing. 

b.  Employ  only  fine  needles  instead  of  the  large  trocars  generally 
iised;  keep  to  our  N°  3  needle  (which  has  an  outer  diameter  of  only  one  and 
a  half  millimetres). 

Needle  N°  4  must  only  be  used  when  the  abscess  is  far  removed  from  tlie 
skin  and  its  contents  very  thick.  In  no  case  should  a  7ieedle  larger  than 
'N°  4  be  used. 

Other  Recommendations. 

c.  Puncture  in  healthy  skin,  at  a  distance  of  4  or  5  cm.  from  the 
abscess,  in  such  a  way  that  the  two  orifices  in  the  skin  and  the  abscess  are 
separated  by  a  long  oblique  track. 

(/.     And  at  each  new  puncture,  prick  the  skin  at  a  new  point. 

How  many  punctures? 

You  may  make  several  punctures  and  injections  (from  7  to  8  and  not 
one  only)  —  for  the  cures  will  be  so  much  more  certain  than  with  one  punc- 
ture only. 

At  what  intervals? 

When  should  the  second  puncture  be  made  ?     Ten  days  after  the  first. 

And  the  others  at  equal  intervals  of  from  10  to  12  days.  After  the 
seventh  or  eighth  sitting,  the  walls  of  the  abscess  are  so  sound,  so  healthy, 
that  it  only  remains  to  seek  for  their  adhesion. 

With  this  object,  at  the  last  sitting,  after  having  made  a  last  puncture 
(without  injection)  you  compress  the  region,  beginning  at  the  extremity  of 
the  limb,  with  layers  of  cotton  wool,  held  in  position  by  2  or  3  Velpeau  ban- 
Jages.  —  Every  four  or  five  days  one  adds  over  this  dressing  a  new  Velpeau 
bandage  which  keeps  up  the  pressure  to  the  degree  required. 

On  the  fifteenth  or  twentieth  day,  the  dressing  is  discontinued.  The 
abscess  is  cured. 

The  duration  of  treatment  of  a  cold  abscess  (essential  or  symptomatic)  takes 
then,  from  two  to  three  months  on  an  average. 

All  well  informed  medical  men  of  today  know  that  of  the 
three     treatments     proposed    for     the     external     tuberculoses 


I"    IN    Till'     TUnEUCl'LOLS    SUPPIUATIONS  li- 

a)  operation,  h)  abstention  ami  c)  puncture  with  injection, 

llie  lasl  is  the  bcsl  (we  Avill  Icll  you  in  Cliai)ler  IV  why  il  is  llie 
best).  Bui  how  many  know  how  to  apph   this  best  Irealmenl!' 

Very  few. 

Often  times,  one  may  sec,  by  the  side  of  abscesses  opened 
by  surgeons,  other  cold  abscesses  which  have  become  fistulous 
in  spite  of  punctures  and  injections,  or  even  because  of 
punctures  badly  made. 

Does  this  mean  liiat  puncture  is  difficult?  No,  not  exactly, 
but  it  must  be  performed  w  ith  scrupulous  care,  and  no  one 
has  ever  taken  the  trouble  to  teach  practitioners. 

Everything-  depends  upon  the  way  it  is  done. 

A^'ell  done,  puncture  cures;  it  is  a  marvellous  method. 

Badly  done,  it  leads  to  failure,  sometimes  to  accidents, 
it  may  even  bring  about  death  (in  the  case  of  abscess  J)y 
gravitation,  of  coxitis  or  of  Pott's  disease). 

This  is  why  it  is  your  pressing  duty,  your  «  sacred  »  duty, 
to  study  their  technique  thoroughly. 

lou  may  make  mistakes  in  three  ways  :  by  instrumentation, 
by  lack  of  asepsis,  by  faulty  technique. 

1°  By  instrumentation. 

You  may  go  to  Avork  (it  is  unfortunately  the  rule)  with 
needles  or  trocars  too  large;  the  orifice  in  the  skin  does  not 
close,  and  there  remains  a  fistula. 

2"  By  lack  of  asepsis. 

On  the  pretext  that  it  is  not  an  abdomen  to  be  opened  and 
that  the  puncture  ought  to  be  repeated,  only  an  indiflfereni 
attention  is  bestowed  to  the  case;  only  a  very  casual  asepsis 
is  made  of  the  hands,  of  the  patient's  skin,  of  the  instruments, 
or  of  the  liquids  to  be  injected. 

And  this  is  particularly  serious ;  for  the  liquids  remaining 
for  some  time  in  a  closed  vessel  will  be  under  the  best  of  condi- 
tions for  giving  birth  to  microbes. 


Il8  Pl]?ICTURES   AND    INJECTIONS.    THE    MATERIEL 

3°  By  the  technique. 

Too  many  or  too  few  punctures  are  made ;  at  intervals  too 
short  or  too  long,  AAitli  liquids  too  active  or  not  active  enough, 
and  that  is  why  the  abscess  persists  indefinitely,  or  even  ends 
by  opening  spontaneously. 

These  are  the  mistakes  which  may  be  made  in  the  course 
of  Ireatment  by  puncture. 

But,  the  mere  fact  of  my  pointing  out  these  faults  will  help 
you  to  avoid  them,  with  a  little  attention  and  method. 

When  all  comes  to  all,  remember  that  this  technique  is  at 
once  very  delicate  and  very  simple. 

Very  delicate,  in  the  sense  that  it  demands  minute  care  and 
a  strict  asepsis. 

Very  simple,  nevertheless,  and  each  of  you,  to  do  it  well, 
will  only  need  to  read,  and  to  remember,  that  which   follows. 

THE  MATERIEL 

The  necessary  instruments  have  been  put  together  by 
Collin,  in  a  small  case  which  every  practitioner  ought  to 
possess,  as  it  may  prove  useful,  not  only  for  the  treatment  of 
external  tuberculoses,  but  also  for  punctures  and  injections  in 
any  other  disease. 

i°The  needles.  —  The  case  includes  a  set  of  four  needles  : 
nos.  I,  2,  3,  4. 

The  needles  nos.  1  and  2,  serve  for  simple  injection ' 
without  preliminary  puncture,  that  is  to  say,  in  cases  of  dry 
tuberculosis  (which  we  shall  deal  with  further  on,  v.  p.  i6/i). 
These  two  needles  have  no  side  holes  :  that  would  be  an 
inconvenience. 

I.     The  dimensions  of  the  needles  of  our  series,  as  made  by  Collin  are  : 


external  diameter 

internal  diameter 

length. 

n°   I 

85/ioo  millimetres 

65/1 oo 

9  centimetres 

n°  2 

ii5/ioo  millimetres 

75/100 

— 

n°  3 

i55/ioo  millimetres 

1 10/100 



n"  4 

200/I00  millimetres 

1 55/100 

— 

THE    ISEEDLK.     Ol  K    ASPIUATOU,    fJLASS    SYRINGE 


'•!) 


On  })iinciple,  you  always  take  the  jincsl  needle  ihe  n'^'  i . 

It  suffices  for  very  fluid  liquids  (iodoformed  ether,  iodo- 
formed  creosote  oil ). 

The  needle  n"  a  is  used  for  liquids  which  arc  rather  viscid, 
such  as  the  gl\cerinaled  naphthol  camj^hor. 


Fig.  lo'i-  —  Everything  necessary  for  puncture  and  injection.  Going  from  left  to 
right  :  sterilized  cotton  wool,  glycerin,  naphthol  camphor,  Calot  case,  tincture  of 
iodine,  ethyl  chloride,  Yelpeau  bandage,  cup,  iodoform  cresote  oil,  sterilized  gauze, 
(a  basin  for  pus).       For  gloves,  see  fig.  io8  and  109,  p.   100. 


The  needles  N°  3  and  4  serve  for  punctures,  that  is  to  say, 
in  tuberculous  suppurations  where  the  injection  is  always  preceded 
by  a  puncture.  The  needles  3  and  4  have  side  holes,  which  is 
an  advantage  here. 

Use  here  in  the  same  way,  for  puncture,  the  finer  needle  (the 


^^r-> 


N-I      N?2    N?3     K-A 


Fig.  io4  bis.  —  These  are  the  external  diameters  (actual  size)  of  the  needles. 
The  n"'  1  and  3  serve  for  injections;   the  n°»  3  and  4  for  punctures. 

N°  3)  :  it  will  protect  you  most  surely  against  the  risk  of  a  fistula. 


I20 


TECHNIQUE    OF    PUNCTURES    A>D   INJECTIONS 


A  needle  smaller  than  N''  3  might  easily  be  blocked  by  the 
more  or  less  clotted  contents  of  an  abscess  ' . 

A  larger  needle  exposes  you  somewhat  to  a  fistula,  I  repeat  it. 


Fig.  1 00.  —  Our  instruments,  A  metal  case  containing  ;  an  aspirator,  a  glass  syringe, 
one  or  more  needles. 

And  that  is  why  you  must  use  iS°  4,  only  in  case  of  necessity, 


I.  Nevertheless,  when  abscesses  are  very  mature,  and  contain  very  serous 
fluid,  the  needle  No.  2  may  suffice  :  try  it. 


FOR  PUNCTURE,  TAKE  NEEDLE  N°  3 


wUcn  you  have  found  N°  3,  previously  tried,  to  be  blocked 
bv  tlie  excessively  thick  contents  of  the  abscess.  You  might 
use  N"  4  when  dealing  with  an  abscess  situated  far  below 
the  surface  of  the  skin  (over  five  or  six  cm.) 

0 


Fig.  io6.  —  Schematic  plate  (Collin).  From  left  to  right  :  glass  syringe,  section  of 
the  aspirator,  needle  ?s°  3  with  an  o,  indicating  the  internal  diameter  of  the 
needle,  a  -wire  having  at  its  extremity  a  screw  for  cleansing  the  needle. 

But  never,  under  any  pretext,  use  the  higher  numbers  5,  6, 
7.  which  you  find  in  some  cases  :  you  Avould  run  a  great  risk 
of  producing  a  large  fistula. 


122        THE   PUNCTURE.    THE    USE   OF   OUR    SMALL    ASPIRATOR 

2°  The  aspirator.  Our  model  (v.  p.  121)  is  very  easy  to 
regulate,  to  sterilize  and  manipulate. 

a.  It  is  regulated  by  means  of  two  screws  E  and  V 
(fig.  106)  at  the  extremity  of  the  glass  tube  and  at  the  end  of 
the  rod  of  the  piston. 

On  tightening  the  thumb  nut  V  Avhich  terminates  the  rod, 
the  asbestos  piston  K  is  enlarged,  and  Avater-tightness  secured. 

On  tightening  the  other  screw  E,  you  ensure  the  contact  of 
the  glass  tube  with  the  two  washers  of  india-rubber  placed  at  its 
tW'O  extremities.  (In  this  Avay  the  vacuum  is  assured.)  The 
screws  are  loosened  when  you  wish  to  take  the  instrument  to 
pieces. 

6.  It  can  be  sterilized  conveniently  by  simply  boiling 
(thanks  to  its  piston  of  asbestos  Avhich  is  not  affected  by  immer- 
sion in  boiling  water  however  much  prolonged) . 

The  capacity  of  the  aspirator  of  the  ordinary  model  is 
only  10  c.c.  But  this  is  quite  sufficient  in  practice,  because 
it  is  easy,  in  dealing  with  a  large  abscess,  to  empty  and  refill 
the  aspirator  as  many  times  as  may  be  necessary  until  the 
evacuation  is  complete.  And,  thanks  to  its  small  capacity, 
it  has  the  advantage  of  allowing  one  to  evacuate  the  abscess 
progressively,  and  without  any  danger  (or  scarcely  any)  of 
causing  the  wall  of  the  abscess  to  bleed,  while  that  danger 
exists  in  using  aspirators  of  larger  capacity. 

This  small  aspirator,  Avith  its  10  cm.  c.  is  almost  too  large 
for  aspirating  certain  small  abscesses,  for  example,  broken  doAvn 
cervical  gland;  in  that  case,  it  would  be  wise,  in  order  not  to 
draw-  blood,  to  open  the  cock  but  very  little,  so  as  to  draw  off 
the  pus  drop  by  drop.  And  as  soon  as  a  depression  in  the 
skin  is  produced  showing  that  the  Avails  of  the  abscess  have 
come  in  contact,  or  Avhen  the  pus  issues  slightly  tinged,  you 
immediately  turn  the  cock  of  the  aspirator. 

All  you  have  to  do  to  make  the  aspirator  ready,  so  as 
to  create  a  vacuum,  is,  the  cock  being  closed,  to  draAV  the 
stem  of  the  piston  up  to   the  end  of  the  barrel  and  give  it  a 


STERILIZATION   OF   THE    MATERIAL    USED   IX    PLNGTURE  123 

quarter  of  a  lurn,  \\\\en  a  notch  tlierc  allo\Ys  it  to  he  fixed  In 
that  position. 

3°  The  syringe.  Tiie  glass  syringe  may  easily  be  boiled; 
it  is  adapted  like  the  aspirator,  to  the  flange  of  the  needle. 
Aspirator  and  syringe  could,  in  case  of  necessity,  supplement 
each  other,  hut  it  is  necessary  to  have  the  two,  because,  in  the 
first  place,  one  is  never  taken  unawares,  and  in  the  second,  it 
is  much  more  simple  to  aspirate  with  the  aspirator,  by  reason 
of  its  cock  Avhich  allows  a  vacuum  being  secured  before  using 
it.  And  it  is  also  easier  and  more  natural  to  inject  with  the 
syringe  than  with  an  aspirator,  especially  when  an  injection 
has  to  be  made  without  a  preliminary  puncture. 

Our  aspirator  being  ((  in  order  »  (where  the  vacuum  is  perfect) 
you  hold  it  in  the  right  hand,  whilst  the  left  hand  holds  the 
needle,  the  evacuation  is  made  without  any  traumatism;  on  the 
other  hand,  when  you  aspirate  with  a  syringe  which  it  is  impos- 
sible to  exhaust  beforehand,  you  always  produce  jerks  and 
repeated  pullings  on  the  Avail  of  the  abscess.  The  jerks  are 
painful  to  the  patient,  they  cause  slight  hoemorrhage,  they  inter- 
rupt, at  every  movement,  the  contact  between  the  needle  and 
the  syringe. 

You  will  find,  besides,  in  the  Collin  case,  one  washer  of 
asbestos  and  two  reserve  india-rubbers  (and  you  might  also  ask 
for  the  addition  of  a  spare  glass  barrel  for  the  aspirator,  which 
you  could  easily  adapt  yourself). 

The  permeability  of  the  needles  is  provided  for  by  the  addi- 
tion of  a  metallic  thread  (cleaning  wire). 

The  cleaning  Avire  of  needles  n"^  3  and  4  has  a  screw 
thread  cut  at  its  extremity;  this  allows  of  its  acting  as  a  cleaning 
brush  (each  time  it  is  used). 

The  method  of  sterilizing;  the  instruments. 

The  aspirator  and  syringe  (previously  taken  to  pieces)  are 
placed  with  the  needles  in  the  small   metal  case.     The  case, 


124  TECHMQUE    OF    PLNCTURE   AND   INJECTION 

opened,  is  plunged  into  a  closed  fish-kettle  full  of  water,  to 
which  has  been  added  some  borate  of  soda,  in  the  proportion 
of  1 5  to  20  grammes  to  the  litre  (this  solution  boils  at  io5°  to 
106°)  '.  The  Avater  at  the  moment  you  plunge  the  case  into  it 
is  cold ;  raise  it  to  boiling  point  —  which  should  be  kept  up 
for  from  half  to  three-quarters  of  an  hour. 

Cleansing  the  instruments. 

After  each  time  they  have  been  used  it  is  necessary  to 
clean  the  instruments  thoroughly. 

The  grease  should  be  removed  first  with  alcohol  and  ether. 
To  thoroughly  cleanse  the  needles  brush  them  through  with 
the  screw  at  the  end  of  the  wire,  already  mentioned.  After 
cleansing,  boil  the  instruments  again.  Afterwards,  wipe  them 
with  gauze  or  sterilized  wool,  or  pass  them  through  alcohol  or 
ether,  Avhen  they  will  dry  spontaneously. 

Give  them  a  coating  of  oil,  insert  the  cleansing  wires  into 
the  needles.  Replace  the  whole  in  the  metal  case,  which  must 
be  always  kept  perfectly  clean. 

Before  each  new  puncture,  boil  the  instruments  again,  but 
this  time  it  may  be  for  five  minutes  only,  if  they  have  been 
boiled  for  half  an  hour  after  they  were  last  used. 

I.  Note  this  well.  It  is  generally  believed  that  the  instruments  must 
be  put  into  the  water  when  it  is  already  boiling,  as  without  this  precaution, 
th(;y  would  be  tarnished.  Well,  it  is  a  mistake,  we  have  never  seen  them 
tarnished  or  damaged  by  placing  them  in  cold  water  gradually  heated  to 
boiling  point;  moreover  in  the  latter  way,  all  risk  of  breaking  the  glass 
barrel  of  the  aspirator,  as  is  likely  to  happen  if  you  plunge  the  instrument 
suddenly  into  boilino;  water,  is  avoided.  I  mvist  warn  you  not  to  pass  the 
steel  needles  through  the  naked  flame  as  it  blackens  and  corrodes  them;  it 
detaches  the  nickle  and  cjuickly  puts  them  out  of  use ;  and  esjJecially  because 
this  method  of  sterilization  is  infinitely  less  certain  than  prolonged  boiling 
for  half-an-hour. 

If  you  possess  platinum  needles,  you  might  pass  them  through  the  flame 
without  detriment ;  but  these  are  very  expensive  (they  cost  five  or  six 
times  as  much  as  the  needles  of  nickled  steel.  It  is  then  more  practical  for 
you  to  keep  to  the  latter.  If  the  nickelling  is  good,  if  they  are  well  cleansed 
each  time  after  use,  then  oiled  over,  the  steel  needles  can  be  preserved  for 
an  indefinite  time,  in  spite  of  repeated  boilings. 


THE    NATURE   OF   THE    INJECTIONS    FOR    COLD    ABSCESS 


I  T.) 


THE  MODIFYING  LIQUIDS  FOR  INJECTIONS 

There  is  an  inlinilv  of  medicated  agents  suggested  for  the 
local  modification  of  external  tuberculoses. 

None  of  these  substances  is  infallible,  but  there  are  four  or 
five  at  least,  Avhich  are  good,  with  which  it  is  possible  to  obtain 


Fig.  107.  —  The  pure  camphorated  naphlliol  in  water  If  you  allow  a  few  drops  of 
camphorated  naphthol  to  fall  into  water,  it  remains  in  a  state  of  separated  sphe- 
rules which,  if  they  were  introduced  into  the  blood  stream,  would  possibly  cause 
embolism.  These  spherules  are  not  produced  when  you  throw  into  the  water  a 
few-  drops  of  the  mixture  of  naphthol  and  glycerin  which  has  been  well  shaken. 


a  cure,  provided  that  you  know  how  to  use  them;  for  the 
technique  is  a  more  important  thing  than  the  nature  of  the 
injection,  and  there  are  medical  men  Avho  will  never  arrive  at 
a  cure  with  liquids  of  any  kind. 

I  do  not  mean  to  say,  hoAvever,  that  all  these  liquids  are 
equally  valuable,  far  from  it,  seeing  that,  after  having  tried 
them  all,  I  enjoin  you  to  keep  to  the  two  following  ones  which 
will  suffice  for  all  your  needs  a)  iodoformed  oil  and  cresole, 
and     6)  the  glycerinated  naphthol  camphor. 


126       COLD    ABSCESS.     WE    OJECT    EITHER   THE   lODOFORMED 

But  I  have  already  spoken  of  them  and  have  given  the 
formula  at  the  beginning  of  this  chapter  (v.  p.  ii5). 

Another  word  upon  the  subject  of  glycerinated  naphthol 
camphor.  Before  injecting  this  mixture,  you  must  make  sure 
that  it  is  miscible  with  water.  You  throw  a  drop  into  a  basin 
of  water  and  shake  it.  If  the  drop  of  the  mixture  does  not 
disappear  in  the  water,  increase  the  proportion  of  glycerin,  stir 
well  the  new  mixture  and  again  perform  the  control  experiment 
in  the  Avater.     (Doctor  Cayre,  of  Berck). 

A  propos  of  the  indications  for  the  tAvo  liquids,  I  would 
add,  that  the  naphthol  camphor  should  be  preferred  for  an 
abscess  not  yet  ripe,  for  example,  those  large  swellings  where 
one  AvithdraAVS  only  a  feAV  drops  of  pus,  the  centre  alone  being 
fluid,  the  rest  of  the  mass  being  formed  of  fungosities  not  yet 
broken  down.  In  injecting  naphthol  camphor  into  the  small 
cavity,  the  abscess  ripens;  each  ucav  injection  liquifies  succes- 
sively the  several  layers  of  the  tuberculosed  Avail. 

And  it  is  for  this  reason  that  a  fcAV  days  after  injection  of 
naphthol  camphor,  Avhen  making  a  neAV  puncture,  one  Avith- 
draAVS  a  larger  quantity  of  pus  than  at  the  first  puncture,  a 
larger  quantity  on  the  third  than  at  the  second,  etc. 

As  soon  as  the  softening  appears  complete,  it  is  better  (as  I 
said  before)  to  continue  and  complete  the  treatment  with  the 
injection  of  cresoted  oil. 


lodoformed  Ether  is  an  active  and  efficacious  liquid,  but  it  is  not 
without  drawbacks;  it  causes  pain  and  is  especially  liable  to  cause  separation 
and  sloughing  of  the  skin. 

It  ought  never  to  be  used  in  cases  where  the  skin  is  already  thin  and  red- 
dened;  it  may  produce  rupture  of  the  skin,  by  the  tension  it  sets  up.  True, 
one  may  let  it  run  out  again  partly  or  wholly;  but  that  mode  of  procedure  is 
neither  very  precise  nor  very  certain.  In  fact,  one  is  never  certain  that  there 
will  not  remain,  in  spite  of  everything,  sufficient  ether  to  distend  the  skin 
beyond  the  limits  of  its  resistance,  —  without  mentioning  the  cases,  rare 
but  nevertheless  always  possible,  where  the  liquid  injected  does  not  return  at 
all,  or,  it  does  not  return  as  much  as  one  would  wish.  (A  parallel  disaster  to 
this  is  sometimes  seen  to  follow  injections  of  tincture  of  iodine  into  the  tunica 
vaginalis,  in  the  treatment  of  hydrocele). 


CREOSOTE,    OH    Till:    CAMl'IK  »UATi:i)    NAPUTHOL    ^V1TII   GLYCERIN        \  9.-J 

There  are  t\>o  cases,  cspcciall\ ,  w  here  vou  should  never  employ  ioJoformed 
ether  : 

a.  The  first  is  in  suppurating  glands  in  the  neck;  with  ether  you  risk 
seeing  the  skin  give  ^^a^,  and  you  know  the  consequence  :  a  liideous  and 
inellaceahle  scar  I 

b.  In  tiie  ahscess  by  gra\ilatioii  of  Pott's  disease,  because  iodoformed 
ether  ma\  cause  a  rupture  of  the  sac  ^into  the  perilonciun  or  intestine. 
(1  have  known  of  liiis  in  several  cases.) 

But  on  the  other  hand,  you  may  employ  iodoformed  ether  «  here  the  skin 
is  quite  soimd,  in  the  abscess  of  hip-disease  or  A\hite  s\Aelling,  or  in  an 
abscess  deeply  situated  in  a  limb,  ^ou  might,  at  anj  rate,  inject  a  small 
quantity,  3  or  6  c.c.  of  iodoformed  ether  —  a  twenty  percent  solution. 

^ou  will  leave  it  to  run  out  two  or  three  minutes  afterwards,  but  if  per- 
chance it  does  not  do  so,  you  need  not  be  alarmed,  for  the  quantity  injected 
is  too  small  to  bring  about  any  untoward  result.  It  is  for  this  reason  that 
you  will  never  on  principle  inject  more  ether  than  the  utmost  cjuantity  you 
know  for  certain  can  be  retained. 

The  tension  produced  by  this  quantity  of  ether  is  not  excessive,  and  it 
doubles  the  certainty  of  the  efficacy  of  the  idoform  injected.  The  proof  that 
the  tension  produced  by  the  ether  is  a  factor  in  the  cure  is  that  you  are  able 
sometimes  to  cure  with  injections  of  pure  ether,  without  the  addition  of 
creosote  or  iodoform,  cold  abscesses,  essential  or  symptomatic. 

How  do  the  injections  act  and  how  do  they  cure? 

The  problem  has  been  solved  in  the  laboratory  of  our  mas- 
ter, professor  Robin,  by  Coyon,  Fiessinger  and  Laurence. 

They  have  shewn  that  the  injections  do  not  act  as  antisep- 
tics; no,  because  of  the  thickness  of  the  wall,  of  the  intricacy 
of  the  cavity,  of  tuberculous  infiltration  in  the  neighbourhood 
and  also  of  the  deep  situation  of  the  bacilli,  the  «  antisepsis  »  of 
tuberculous  abscess  is  as  illusory  as  intestinal  antisepsis. 

The  injections  act  by  provoking  a  great  afflux  of  white  cells, 
of  polynuclear  cells,  afterwards  destroying  them,  thus  setting  at 
liberty  certain  ferments ;  the  first  is  a  lipolytic  ferment  having 
the  property  of  attacking  the  fatty  envelope  of  the  bacillus,  later 
on,  a  proteolytic  ferment  (a  proteose)  having  the  property  of 
liquefying  and  digesting  albumenoids,  that  is  to  say,  of  des- 
troying the  very  substance  of  Koch's  bacillus. 

The  Method  of  sterilizing  the  modifying  liquids. 

You  may  sterilize  them  yourself,  as  we  are  in  the  habit  of  doing. 


120  PUNCTURE   OF   AN   ABSCESS.    THE   INDICATIONS   FOR  PUNCTURE 

To  sterilize  the  first  liquid,  the  creosote  oil,  you  begin  by 
boiling  the  oil  for  half  an  hour.  (If  the  oil  is  of  good  quality, 
if  does  not  blacken  on  boiling.)  Then  you  allow  it  to  cool, 
and  throw  into  it  the  creosote,  the  gaiacol  and  the  iodoform,  all 
chemically  pure,  and  lastly  you  add  the  ether.  For  the  second 
liquid  (naphthol,  camphor  and  glycerin)  you  boil  the  glycerin 
for  tAventy  minutes  (it  boils  at  i5o°),  then  allow  it  to  cool,  and 
throw  into  it  the  desired  proportion  of  i/6  to  1/7  of  naphthol 
camphor  prej)ared  aseptically  by  your  pharmacist,  under  your 
direction. 

Itgoes  without  saying  that  you  will  boil  the  flask  and  the  cups. 

Lastly  you  Avill  take  care  to  preserve  the  liquids  in  well 
stoppered  flasks,  keeping  them  protected  from  the  light. 

TECHNIQUE  OF  THE  PUNCTURE 

We  have  to  speak  here  of  the  technique  only.  The  dia- 
gnosis of  cold  abscess  and  the  study  of  exploratory  puncture 

(as  a  means  of  diagnosis)  Avill  find  their  place  better  elsewhere, 
(v.  chap.  XIX). 

However,  we  ought  to  say,  now,  a  few  words  on  the  indica- 
tions for  puncture  in  the  treatment  of  cold  abscess. 

The   indications  for  puncture   in   cold  abscess, 
a.     Is  it  necessary  to  puncture  every  abscess? 

Yes,  if  it  is  an  abscess  you  are  able  to  reach  without  the 
risk  of  wounding  some  important  organ.  Suppose  you  are  in 
the  presence  of  a  deep  abscess  of  the  internal  iliac  fossa ;  wait 
to  puncture  it  until  it  has  become  superficial. 

b.  Why  puncture  the  abscess  instead  of  trusting  to  its 
spontaneous  resorption? 

P'.  Because  spontaneous  resorption  is  the  exception,  and 
by  thus  Avaiting,  you  run  the  risk  of  seeing  the  abscess  unexpect- 
edly invading  the  deep  surface  of  the  skin ;  after  AA^hich  you 
are  no  longer  certain  that  you  Avill  be  able  to  prevent  its  rupt- 
ure and  a  consequent  fistula. 


WHEN     OlCIir    A    COLD     AliSCI'SS    TO    HE   OI'ICM.I) 


I2ij 


:>"'"-^.  J>erans('.  in  llic  casculicrc  rcabsorpllon  lias  ocrmrod, 
il  requires  a  rcry  loinj  lime  (one  or  several  years). 

3""J.  Because  \\  Ikii  llie  abscess  has  been  reabsorbed,  llic 
cure  is  not  so  sure  and  nol  so  definite,  in  a  general  way,  as 
with  llie  abscess  wlilcli  lias  been  cured  by  puncture  and  injcclinn. 

In  fad.  wlu'ii  \\c  sa\  llial  a  cold  abscess  is  reabsorbed,  llial 
means  ihal  llicrc  is  no  more  liquid,  l)ul  sniel\  nnl  ilmi  all  (lie 
infecled  and  inlccling  elements  in  its  wall  ba\e  disappcan-d. 
The  cold  abscess  lias  perbaps  simply  returned  to  its  i'oriner 
condition,  tbat  of  a  tuberculoma  and  al  lliis  time  even  ibnugli 
Ibere  is  nothing  to  be  felt  on  palpation,  it  ma}  still  retain 
bacilli  Avbicli  are  quiescent,  and  in  fact,  one  has  often 
observed  the  return  of  these  abscesses  so  called  "  reabsorbed  ". 

On  the  contrary,  Avhen  the  contents  of  such  an  abscess  and 
the  morbid  elements  in  its  Avail  haAe  been  got  rid  of  by  sue- 
cessiAe  punctures',  one  can  conceiAC,  and  clinical  obserAation 
confirms  it,  that  the  cure  obtained  should  be  more  complete. 

4^'''^.  A  last  reason  for  employing  j^i^^nctures  and  injec- 
tions in  abscess  by  gravitation  is,  that  the  liquid  injected  does 
not  act  only  on  the  abscess  to  be  cured,  but  it  reaches  the  bone 
and  the  articulation  AAhich  haA^e  caused  the  abscess,  rendering 
them  sound  and  cicatrising  them.  —  So  much  so  that  it  may 
be  said  in  all  truth  that  the  patients,  provided  that  aac  treat 
them  by  puncture  and  injection,  Avill  be  cured  more  quickly 
and  surely  than  if  they  had  not  bad  an  abscess. 

When  ought  one  to  puncture  ? 

Immediately  the   abscess   is  recognised  (except    in    the   case 

I.  We  are  in  tlieliabit  of  saying,  at  tlie  familiar  causeries  in  our  practice, 
ttiat  it  is  better  to  see  an  abscess  in  a  receiver  tlian  trust  to  its  absorption  into 
tlie  tissues. 

Ho\vever,  A^hcn  llic  general  condition  of  the  patient  is  very  bad.  one 
ouglit  to  wait  a  white ;  in  tlie  mean  time,  do  nothing  more  llian  is  absolutely 
necessary  in  the  way  of  local  treatment,  to  prevent  the  opening  of  large 
abscesses.  In  such  a  case,  endeavour  in  every  \\  ay  to  improve  itie  general 
condition  of  the  patient.  But  we  shall  see  about  that  in  tlie  cliapter  on  mul- 
tiple tuberculoses  (chap  .xx.j 

Calot.  —  Indispensable  orthopedics.  9 


l3o  TECIIMQUE    OF    THE    PUNCTURE    OF    ABSCESSES 

already  ciled  of  a  deep  iliac  abscess  or  a  retropharyngeal 
abscess).  It  is  necessary  to  begin  before  the  skin  has  been 
invaded,  before  it  has  become  reddened  or  thin.  If  not,  it  will 
he  too  late  to  save  the  skin  already  inoculated,  already  invaded 
by  tubercles  in  the  abscess  "wall';  you  would  not  be  certain  of 
escaping  a  fistula  and  its  terrible  consequences.     And  even  ^vhen 


Fig.  io8  Fig.   109 

Fig.  108  and  loq.  —  Mittens  made  at  llie  lime  of  llie   operation,  "nilh   sterilized  com- 
presses for  the  case  "where  vou  have  touched  septic  matter. 
Fig.  108.  —  The  method  of  making  a  mitten.       Fold  a   compress  inio  two,   lay  the 
hand  flat  on  the  square  so  made,  cut  the  two  thicknesses,  following  the  outline  and 
baste   them   together   or  stitch  them  with   the  machine  following  the  dotted  line. 
Fig.  log.   —  Afterwards  turn   them  inside  out  «  like  a  glove  »   so  that  the  sewing 

is  inside. 

this  red  and  thin  skin  does  not  break,  it  ^vill  very  likely 
be  puckered  and  pigmented;  Avhich,  in  the  neck,  for  example, 
is  always  as  hideous  as  a  veritable  cicatrix. 

I.  In  tlie  same  wav  tliat  llie  skin  of  the  breast  may  be  invaded,   after  a 
certain  time,  by  malignant  growths  of  llie  subjacent  gland. 


AMlSLl'TiC    rULCAL  TIU.NS 


i3i 


The  Puncture. 


The  palient  Is  lell   in    bed.  or    bcllcr  slill.  placed   upon   a 
table,  llie  region  of  the  abscess  Avell  exposed. 

Ilav(^  at   hand  the  necessary  objects  (v.    fig-.    lo'i),  \\\r   case 


Fii;.  1 10.  —  An  opening  arranged  in  a  corset  of  plaster  to  allow  of  the  puncture  of 
an  iliac  abscess.  At  the  moment  of  puncture,  the  edges  of  the  opening  will  be 
covered  with  sterilized  towels,  in  the  wav  she>Yn  in  the  following  figure,  tig.   iii. 

containing  the  three  sterihzed  instruments,  the  tincture  of 
iodine,  the  cup,  the  two  flasks  of  hquid,  and  the  dressing. 

You  proceed  to  make  the  toilet  of  your  hands  and  of  the  patient, 
taking  as  much  pains  as  if  \ou  were  going  to  open  an  abdomen. 

a.  Toilet  of  the  hands.  —  Rub  the  hands  for  several 
minutes  wilh  a  coarse  brush  in  oxygenated  water  (this  is 
particularly  recommended),  or,  ^vash  them  thoroughly  in  Avarm 
soapy  water;  after  that,  rub  them  with  alcohol  and  ether  and 
steep  them  in  a  warm  solution  of  sublimate,  one  in  a  thousand. 


I  32 


PUNCTURE    OF    A   COLD    ABSCESS 


It  AYOulcl  Le  better  to  Avear  india-rubber  gloves.  They  are 
indispensable  when  you  have  been  touching  wounds  or 
matter  which  is  septic.  In  default  of  gloves,  postpone  the 
puncture  until  the  next  day  unless  there  is  extreme  urgency , 
(for  examjDle  in  the  case  of  an  abscess  Avhich  is  about  to  open), 
in  which  case  you  might  make  a  puncture,  without  an  injec- 


Fig.  III.  —  Where  you  see  from  periphery  to  centre  :  i"  the  feneslralei  compress 
surrounding  the  abscess  zone;  2.  a  dark  patcli  representing  the  skin  painted  with 
iodine,  and  3.  in  the  centre  of  the  dark  patch,  a  white  area  representing  the  part 
anaesthetized  with  ethyl  chloride. 


having    smeared 


your    fmgers    with    tincture    of 


tion,     after 

iodine,  or  rubbed  them  Avell  with  benzole  or  iodized  alcohol, 
touching  the  instruments  only  Avith  the  hands  protected  by 
compresses  or  large  squares  of  gauze  well  sterihzed  (by  boiling) ; 
or  better  still,  with  foiirrecmx  similar  to  infants'  gloves  or 
"  mittens  ",  Avhicli  have  been  prepared  on  the  spot,  by  some 
one  of  the  family,  with  tw^o  compresses  stitched  by  three  of 
their  edges  (v.  fig.   io8  et  109),  and  afterAvards  boiled. 

b.  Asepsis  of  the  patient's  skin.  —  Asepsis  is  produced 
noAvadays  by  simple  painting  Avith  fresh  tincture  of  iodine,  by 
means  of  a  small  brush  or  a  piece  of  cotton  avooI  (v.  fig.  iii), 
without     previous     Avashing    or     brushing.       I     should    say, 


TML:    NLLKLi;    1 


s   MVDi.   r<>    ii>ii.i»\N     \-   M  ll^    oiti.iiji  i;    iiuck     \'.VA 


jll,,,,il    iiiiiuciliali^   uasliiiii^-.    lur  a    wasliiii--  done    llic  evciiirif,' 

before  can  onl\  be  beneficial. 
'I'lic   riiMiiire  oC   iodine   is 
ailnwed  lo  diN  forlwoor  ibrec 
uiiiuiles.      Painl     it     uidelv, 


Fi^.  112.  —  How  not  to  puncture,  for 
if  YOU  force  the  needle  through  the 
wall  perpendicularly,  its  course 
through  the  soft  tissues  will  be  very 
short,  the  parallelism  of  the  walls 
of  the  small  wound  would  still  re- 
main when  the  needle  is  withdrawn  ; 
these  conditions  facilitate  the  infec- 
tion of  the  abscess  bv  pus,  which 
niav  exude. 


Fi^.  ii3.  —  How  one  ought  to 
puncture.  The  puncture  is  very 
oblique  ;  the  track  is  much  Ion- 
iser (A):  on  the  other  hand,  the 
retraction  of  the  soft  tissues  does 
away  with  the  parallelism  of  the 
sides  of  the  wound,  making  a 
track  «  en  chicane  »  (B). 


that  is  to  say,  over  a   siuface  as  large,   at  least,   as  twice  liie 
size  of  the  palm  of  the  hand. 

The  advantage  of  this  extensive  painting,  is  to  prepare  a 
place  for  the  contact  of  the  left  hand,  which  has  to  fix  the  skm 
Avhilst  the  right  hand  pushes  in  the  needle.  For  the  same  pur- 
pose, and  as  an  additional  precaution,  a  large  (boiled)  compress 


r34 


TECHNIQUE    OF    THE    PUNCTURE    OF    COLD    ABSCESSES 


is  applied  over  the  region,  an  opening  being  cut  out  of  the  centre, 
leaving  uncovered  a  square  of  6  to  8  cm.  wade,  in  the  middle 
of  which  is  the  place  chosen  for  the  puncture.  All  the  surface 
of  skin  left  bare  should  be  painted  with  tincture  of  iodine. 

After  the  puncture,  you  remove,  with  a  tampon  impregnated 
Avith  alcohol,  what  remains  of  the  tincture  of  iodine,  for  if  it  is  not 
very  fresh  it  may  cause  desqviamation  or  even  vesication  of  the  skin . 

During  the  four  or  ten  minutes  required  by  the  tincture  of 
iodine  to  dry,  you  put  in  order  the  aspirator,  that  is  to  say, 
you  make  the  vacuum,  and  you  charge  the  syringe. 

If  you  wait  to  make  the  vacuum  until  the  needle  has  been 
forced  in,  you  may  have  the  pus  spurting  out  and  soiling 
everything,  before  the  aspirator  is  ready.  The  aspirator  and 
syringe  are  afterwards  placed  in  a  dish  close  at  hand. 

The  puncture. 


You  use  needle  n°  3. 

Where  must  you  prick  the  skin.^  At  a  point  a^vay  from 
any  veins  which  are  visible  beneath 
the  integuments,  and  at  a  distance  of 
three  or  four  cm.  from  the  cu.taneous 
zone  of  the  abscess,  in  such  a  way  as 
to  enter  by  an  oblique  track  (instead 
of  pricking  the  skin  vertically  and 
going  straight  into  the  abscess). 

This  obliquity  is  advantageous  for 

deep  abscesses,  and  indispensable  for 

„  ^  ,  , ,    superficial   ones,   especially  subcuta- 

Fig.   ii/i.  —  The   needle   is  held  -i  '         i  J 

between  the  thumb  and  second    neOUS      absCCSSCS     (fig.      112).       TllOSC 

fingerservingasguide  the  first  ^\,q^M   ucvcr  enter  except  by  a 

finger  pushing  on  the  head  (or    J  ±  ^ 

hold  it  as  you  would  a  trocar  very  obliquc  track  and  almost  paral- 

or  ^vriting  pen).  j^^   ^^   ^^^^   g|^-^_ 

Thanks  to   this    obliquity  (fig.    ii3)   the   lips  ot   the   deep 
extremity  of  the  needle  track  will  play  the  part  of  a  valve  and 


TOCOMIRESS   TllF.   ABSCESS    IN    OUDF-Il   TO    lACIMTATE    PLNCIUU:£       [A'i 

\nr\vn[  the  ronlciils  nl  llic  al)S("os'<  fiDin  escai)iii,i:'  oulw  aidl  v,  as 


Fig.   1 1 5.  —  Abscess  of  the  right  iliac  fossa  :  the  collection  forms  a  thin  sheet 
in  the  midst  of  the  depressible  soft  tissues . 

the  needle  is  Avithdrawn.     Moreover,  in  pricking  the  skin  four 


Fig.    ii6.  —  The  abscess  in  the  preceding  figure.      The  sheet  of  pus  verv 
much  spread  out. 

or  five  centimetres   from    the   cutaneous  zone    of   the   abscess, 
one  passes  through  sound  skin  ;    and  that  is  very  important. 


i3G 


TECHNIQUE   OF    ABSCESS    PUNCTURE 


Ansesthesia  of  the   skin.  —  At   the  place  thus   selected 
(fig.  Ill)  ethyl  chloride  is  sprayed. 


/ 


ji^io     ii-y.  — When  you   proceed  to  puncture  tlie   abscess,    the  needle  depresses   the 
skin  before  it  enters  the  collection.       Look  at  the  following  figure. 

As  soon  as  the  skin  is  blanched  over  an  area  the  size  of  a 
live    shilling   piece,    take    the  n°  3    needle  in  the   right   hand 


Y\a.  ii8.  —  The  pressure  of  the  needle  (v.  fig.  117)  drives  aside  the  pus  of  "which 
but  a  little,  very  thin  sheet  remains,  liable  to  be  traversed  by  the  needle,  -without 
any  result.  This  would  be  a  a  ponction  blanche  ))  (a  failure),  although  a  great 
quantity  of  pus  is  present.  The  index  finger  presses  firmly  on  the  head,  then  the 
skin  is  fixed  by  the  index  finger  and  the  thumb  of  the  left  hand. 


iio\\   TO  MAkf-    run  am^ckss  contents  tense 


'•^7 


(fig.   ii'i)   and   lioKl  il  l)\    llif    iiild.lle   l)el\\ccii  llic  llmnih  ;iiii| 
second   finger,    wliilsl    llic   iiidix    linger  presses    firmly  on    llio 


I'ig.   III).  —  ^^  hat  it  is  necessary  to  do  to  puncture  this  abscess  (see  the  four  preced- 
ing figures).       An  assistant  presses  firmly  on  the  peripherv  of  the  abscess. 

liead ;  tlien  the  skiu  is  fixed  bv  the  index  finger  and  the  thumb 


Fig.  120. —  The  assistant  in  this  way  (see  fig.  1 19)  causes  the  fluid  to  flow  back  to  a  single 
point  where  it  should  be  easy  to  attack  it  with  the  needle,  by  an  oblique  puncture. 

of  the   left    hand  at    one  or    two  centimetres   from    the   point 
chosen  for  the  puncture ;  you  could,  moreover,  direct  an  assist- 


[38 


PUNCTURE  OF  TUBERCULOUS  SUPPURATIONS 


Fig.    121.    —    As    soon    as    anaesthesia    is  oblained,  you  sirelcli  the   skin   with    the 
thumb  and  index  finojer  of  the  left  hand  and  thraslthe  needle  with  the  ria;ht  hand. 


Fio.  122.  —  In  order  to  adjust  the  aspirator  to  the  needle,  hold  the  outer  end  of  the 
latter  between  the  thumb  and  index  finger  of  the  left  hand  so  as  to  prevent  any  dis- 
placement of  the  point.  This  adjustment  once  assured,  the  left  hand  opens  the  cock 
of  the  aspirator. 


I'lNCTLRE   OF     llir    SKIN. 


AsiMiiA HON   r)i    iiii:   vi- 


1 3f) 


ant  l(^  piisli  the  abscess  tOANards  \ou,  pressinj,^  it  witli  one  or 
belli  hands  on  tlie  opposite  part  ol'  the  region;  you  then  plant 
Nonr  neetlle  in  the  skin,  you  push  A\ith  a  firm  and  sustained 
clTortjSO  llial  iho  integuments  are  traversed. 

The  congealed  skin  is  sometimes  very  difficult  to  pierce, 
and  \ou  need  to  pusli  firmly;  but  it  is  necessary  as  soon  as 
the  skin  has  been  traversed,  to  moderate  vour   force,  so  as   to 


Fig.  123.  —  After  that,  still  holding  the  aspirator  and  ihe  needle  in  the  right  hand, 
the  left  hand  presses  gently  on  the  abscess  wall. 


go  through  the  soft   tissues  gently  up  to  the  point  Avhere  you 
judge  pus  Avill  be  found. 

AVhen  you  arrive  at  the  Avail  of  the  abscess,  you  usually 
feel  a  slight  resistance;  and  you  should  press  a  little  to  get 
through ;  but  as  soon  as  you  are  in  the  sheet  of  liquid,  al 
resistance  has  disappeared;  you  have  a  special  sensation, 
which  you  at  once  recognise.  You  feel  thai  the  deep  extre- 
mity of  the  needle  moves  about  with  a  certain  freedom,  — 
which   it  would  not  do    if  it   were    not  in   the  abscess  itself. 

Fairly  often,  a  small  drop  of  pus  oozes  from  the  end  of  the 


i4o 


TECHNIQUE    OF    ABSCESS    PUXCTURE 


needle.  But,  generally,  the  pus  does  not  issue  sponta- 
neously; hence  the  evident  necessity  for  aspiration,  which  is 
infinitely  preferable,  need  it  be  said,  to  the  rough  pressing 
practised  by  some  practitioners  on  the  region  of  the  abscess, 
to  obtain  the  discharge  of  pus;  traumatic  pressures  causing 
bleeding  and  creating  the  risk  of  inoculation  —  and,  moreover, 
being  very  often  ineffective  in  bringing  about  the  evacuation. 


Fig,   i2'4.   —   When  the  aspirator  is  full,  the  pus  is  emptied  into  a  small  basin. 


You  stop   the  needle   with  the  left  index  fmger, 
right  hand  takes  from  the  basin  the  aspirator  already 
which  is  then  adapted  to  the  lumen  of  the  needle. 

When  this  adaptation  is  complete,  the  left  hand 
valve,  the  pus  immediately  fills  the  aspirator  (held  in 
hand) ;  you  then  close  the  valve  and  withdraw  the 
from  the  needle,  which  remains  in  its  place.  Before 
the  aspirator  you  place  and  leave  a  small  piece  of 
cotton  wool  round  the  needle,  to  absorb  any  drops  w 
flow  while  you  empty  the  aspirator. 

You   empty   the  aspirator,  you  exhaust   it  again 


while  the 
prepared 

opens  the 
the  right 
aspirator 

removing 
sterilized 

hich  may 

and   you 


Tin:  iMr.crio.N  wiiicii  i-olluws  the  en aclaiion  or  I'u.s    i/|i 


rciula[)l  il  li>  llic  needle;  and  so  on  aj^aiii  and  aiiain,  niilil  ihe 
abscess  is  eniplv. 

One  recognises  thai  llie  abscess  is  empiN  l)\  il>  having 
colla[)sed;  and,  \\hen  it  is  snpcrFicial,  h\  its  ciilaneous  Avail 
being  deepened  into  a  hollow,  and  1)n  ihcie  being  no  longer 
any  appreciable  fluclualion. 

Is  it  necessary  to  try  and  empty  an  abscess  thoroughly? 


..^<}l 


Fig.  12  5.  —  Injection.      The  aspirator  is  simplv  replaced  Ijv   the  cliari;ecl 
syringe  whicti  is  adjusted  to  the  needle. 

At  the  commencement  of  the  treatment,  no.  so  that  yon  do 
not  run  the  risk  of  causing  the  wall  to  bleed.  Later  on,  after 
a  series  of  injections,  you  may  empty  it  thoroughly,  because 
then,  if  you  should  withdraw  a  few  drops  of  blood,  that  would 
cause  no  inconvenience,  the  pus  being  sterile  at  this  time. 

The  abscess  being  emptied,  one  avoids  washing  the  parts; 
it  would  be  prolonging  the  operation  uselessly,  and  even  run- 
ning a  slight  risk  of  infecting  the  abscess. 

There  remains  to  be  done  : 

The  Injection. 

For  this,  you  simply  replace  your  aspirator  by  tlie  s\ringe 
already  charged,  and  you  push  in  the  injection. 


1 42  TECHNIQUE  OF  THE  PUNCTURE  OF  TUBERCULOUS  SUPPURATIONS 


We  have  indicated  above  the  liquid  which  should  be 
chosen  :  nearly  ahvays  the  creosoted  oil;  and  the  quantity  which 
should  be^injected  :  for  large  abscesses,  never  more  than  from 
ID  to  i4  c.  c.  ;  and  for  small  abscesses  inject  less  thanio  c.  c, 
\  using  a  quantity  equal  to  a  half,  or  a 
third  of  the  quantity  of  pus  Avithdrawn. 

Withdraw    smartly    the   needle 

attached  to  the  syringe. 

Immediately,  you  place  over  the 
orifice  a  tampon  of  wool  or  a  piece  of 
sterilized  gauze,  and,  by  a  few  to-and- 
fro  movements,  you  do  away  with  the 
parallelism  of  the  two  orifices  in  the 
skin  and  the  abscess  wall. 

Finally  you  apply  lightly  a  com- 
pressive dressing,  in  place  of  the  sim- 
ple layer  of  collodion  usually  employed, 
which  does  not  sufficiently  guarantee 
against  infection.  And  do  not  touch  it 
again  for  several  days,  until  the  second 
puncture.  - 

-  ^- j'j?:  When  should  the  second  punc- 

Fig.  12G.  —  Abscess  of  the  left  ture  be  msde? 

popliteal  space.  .^.^^-^    ^^^j^^    ^    jj^^^^^     according   tO 

the  case.      It  is  best  made  after  about  ten  days. 

Why  this  delay?  Because  at  the  end  of  that  time  the 
liquid  injected  has  ceased  to  act.  —  This  rule  applies  to 
ordinary  cases,  where  the  skin,  before  you  puncture,  was  in 
very  good  condition ;  for  if  the  skin  were  inflamed  and  atten- 
uated, you  must  inspect  it  next  day,  and  every  following 
day,  to  watch  it  and  guard  against  all  eventualities  Avhich  we 
will  mention  a  little  further  on. 

In  ordinary  cases,  where  the  skin  was  in  good  condition 
(neither  reddened  nor  attenuated)  it  is  useless  to  examine  it  before 


r    IS     >ECESSAll\     TO    M.Vki:    SEVKUAL    I'LNCTUUES 


I  'l.i 


llie  Iciilh  (If  Iwclflli  Jay;  at  lliat  dale,  a  new  piinclure  is  made, 
followed  1)\    an    iiijcilioii.      'Hie  skin  is  pierced   at  a  new  place 


Fig.  127.  —  Squares  of  absorbent 
cotton  wool  damped  and  arranged  for 
the  compresion  of  the  abscess  on  the 
completion  of  the  series  of  punctures. 


g.  128.  —  Compressive  bandage  begin 
ning  at  the  toes  and  reaching  far 
above  the  abscess  for  the  purpose  of 
causing  approximation  of  the  walls  of 
an  abscess  of  the  tliiah  or  of  the  nroin. 


on  each  occasion,  so  as  to  avoid  all  risk  of  a  fistula  occurring. 

It   is    preferable    to    make    the  second  puncture  about  the 

t^velfth  day  than  to  postpone  it  indefinitely,  relying  upon   the 

rc-absorplion    of    the   abscess,    a   possible    occurrence,    after   a 


1 44 


PUNCTURE    OF     COLD     ABSCESSES 


single  injeclion.  —  Our  reasons  are  analogous  to  those  Avliich 
have  urged  us  to  puncture  rather  than  ahstain,  namely,  that 
re~ahsorption  does  not  often  occur,  that  in  "waiting  one  loses 
time,  and  supposing  a  case  in  which  this  single  injection  would 
suffice,  the  ahscess  would  not  he  so  Avell  cured  as  it  would  be 


Fig.    129.  —  Abscess  of  the  external 
aspect  of  the  tliigii. 


Fig.  i3o.  —  Tiie  same  abscess  after  punc- 
ture and  complete  evacuation:  tlie  glob- 
ular swelling  is  replaced  by  a  saucer-like 
depression. 


after  7  or  8  injections.  In  the  same  way  an  abscess  treated 
by  injections  Avill  he  better  cured,  as  avc  have  said,  than  that 
which  has  re-absorbed  spontaneously,  without  any  injection. 
As  to  the  length  of  the  intervals  between  the  sittings,  I 
know  very  well  there  are  all  manner  of  opinions ;  on  the  one 
hand  are  practitioners  Avho  propose  to  repeat  the  operation 
every  three  days;  on  the  other  hand  there  are  others  aaIio 
consider  the  interval  should   be  three  moiiths.      "S^ell,  I  consi- 


THE  DIFFERENT  APPEARANCES  OF  TURERCULOUS  PUS 

(AND  THE  INDICATIONS  TO  BE  DRAWN  FROM  THEM  AS 
REGARDS  TREATMENT  AND  PROGNOSIS; 


Cliche  J.  Foactlou, 


A.  B.  C.  Non  infccte'drpus  :  Treatment  by  punctures  and  injections. 

A.  Serous  pus,  mahogany  colour   .   1     In   these    2   cases   inject  iodoformed    oil 

B.  Ordinary  pus,  yellowish  green..    )  or  ether. 
C.  Clotted  pus.  —  In  this  case  inject  camphorated  naphtol. 

D.  Sanqinneous  pus,  without  fever,  without  the  odour  of  pus.  —  This  abscess  is  not 
infected  but  runs  a  great  risk,  of  becoming  infected  and  of  bursting.  To  avoid  this 
twofold  danger,  punctures  must  be  performed  as  rarely  as  possible,  without  injections, 
with  slight  compression  afterwards;  by  «  as  rarely  as  possible  »,  Imean  that  punctures 

are  to  be  made  only  if  the  skin  threatens  to  give  way. 

E.  Claret  coloured  pus,  infected,  with  fever  and  the  odour  of  pus.  —  Treatment  :  Try  to 
reduce  infection  and  fever  by  puncturing  every  day  without  any  injection  afterwards. 
If  after  i5  or  20  days  fever  still  persists  in  spite  of  the  punctures  (without  injections), 
resign  your  self  to  incising  and  draining  this  abscess. 


iiii:   iMiuvM.s    i!|.i\\i;i;n    the   injections 


I  |.> 


(lor  llic  Irulli  lies  lirlwccii  llic  Iwo.  IT  ihc  silliiijj;s  are  rr[)cal(.'tl 
loo  (iltiii.  llnif  is  a  ri-^k  nl'llie  skin  «  dc'lcrioraliiig  »  and  of 
inlVclioii  —  and  Jjrsidc  il    wuuld  faligue   llio   palienl.      If  lli(\ 

£^^ 


:2?.---^ 


Fig.  i3i.  —  This  is  the  end  of  the  8lh  aud  last  puncture;  lliis  time,  instead  of  a 
further  injection,  you  apply  compression. 

^^  hen  the  evacuation  is  finished,  you  apply  over  the  abscess  a  pad  of  cotton  wool  mois- 
tened and  squeezed  out;  the  left  hand  resting  on  the  pad,  the  fingers  are  applied 
successively  the  one  after  the  other,  commencing  at  the  part  furthest  removed  from 
the  point  where  the  needle  entered,  causing  the  last  few  drops  of  pus  remaining  lo 
ilow  in  that  direction.    The  aspirator  and  needle  are  then  withdrawn  together,  smarlly . 

are  too  far  apart,  the  cure  of  the  abscess  will  take  a  very  long 
time,  and  a  perfect  result  is  not  so  certain.      Therefore,  neilhci- 


1*  ig.   1 .52.  —  Then  over  all  a  Hat  tampon  and,  lo  perfect  the  compression,   some 
moistened  pads  of  cotton  wool  placed  crosswise  over  the  abscess. 

too  long,   nor  too  short,   —  and   the  best  rule  is  to   make   a 
sitting  every  lo  or  lo  days. 

At     the      seventh     puncture,     the     liquid    you    Avithdrau 
is   no    longer    pus,    but  a  mixture  of   brownish  serosity    and 

Calot.  —   Indispensable  orthopedics.  lo 


1 46  PUNCTURE  OF  THE  ABSCESS.   AFTER  SEVEN  PUNCTURES  ONE 

of  modfying   liquid   sometimes    slightly   tinted  of  a    rose    co- 
lour.     Very  often  also,    at  this    time,  one  notices  in  the  con- 


Fig.  i33.  —  Two  or  three  weeks  after,  you  remove  tlie  compress  and  make  an  inspec- 
tion. If,  as  shewn  here  (but  it  is  an  exception)  a  small  quantity  of  pus  still  appears, 
it  is  collected  at  a  single  point  instead  of  being  distributed  over  the  whole  wall  of 
the  abscess.  Puncture  at  this  point  without  removing  the  pad  of  wool,  which 
should  remain  in  position  after  the  puncture,  and  over  it  replace  the  tampons  cross- 
wise so  as  to  renew  the  compression  which  should  be  maintained  evenly  for  three  weeks. 

tents  of  the  abscess,  some  of  the  liquid  injected,  unaltered*. 
If,    after   seven   punctures    and    injections,   liquid    is  again 


Fig.  i3i.  —  The  disposition  of  the  moistened  tampons  for  compression  of  the 
culs-de-sac  about  the  elbow. 

I.  Tlie  bacteriologists  explain  this  (refer  to  p.  127),  by  saying  that  at  the 
beginning,  as  a  result  of  the  first  injections,  a  lipolytic  ferment  is  for- 
med, having  the  property  of  digesting  fatty  matter  (such  as  the  oil  of 
our  injections) ;  a  little  later,  a  proteolitic  ferment  appears,  which  digests 
albumenoid  substances,  hiit  leaves  intact  the  oil  of  our  solution. 


EXERTS   PRESSURE    TO   AITIU  (XIMVTK  THE    WALLS   OF    THE   AliSCESS      I 'l" 

Iniiued.   wliicli   is    ihc  rule.    \,.ii   will   make  an  eighth  jjuiicliirc, 
l>iil  lliis  lime  without  injection. 


Fig.   i35.  —  Compression  of  the  cul-de-sac  of  the  instep. 

And   you  Avill  at  once   compress    the  region   Avith  pads  ol' 


Fig.  1 30.  —  To  avoid  the  vessels,  they  are  marked  out  tv  (he  index  and  second  fin- 
gers of  one  hand  and  pushed  on  one  side,  while  the  other  hand  pushes  in  the  needle 
two  centime'.res  outside  them. 


1 48  PL?<CTURE    OF    A?{    ABSCESS.    POSSIBLE    MISHAPS 

■wool  placed  cross-^vise,  and  Yelpeau  bandages,  to  promote  the 
approximation  of  the  abscess  Avail,  from  that  time  sound  and 
secure  (fig.    i3i.    182.    i33.    i34-    i35.). 

This  compression  you  maintain,  and  even  if  possible 
increase,  by  adding  every  four  days  one  or  t^vo  Velpeau  l^an- 
dages  over  the  compressive  dressing-  (Avithout  undoing  it). 

This  dressing  remains  in  place  for  from  i5  to  20  days. 

When  you  eventually  remove  it,  approximation  of  the  Avails 
of  the  pocket  has  been  effected ;  the  abscess  is  cured. 

Aine  times  out  of  ten  this  Avill  be  the  course  of  cAents ; 
very  regularly,  Avithout  incident,  Avithout  a  slip. 

The  tenia  time,  certain  incidents  may  arise  AAhicli  Avould 
disconcert  you  perhaps,  if  you  Avere  not  fore-Avarned ;  but  you 
may  easily  OAcrcome  them,  after  having  read  the  folloAving 
chapter,  -which  may  be  entitled  :  — 

Possible  incidents 
in  the  course  of  punctures  and  Injections. 

A.  —  IMMEDIATE  INCIDENTS. 

Avhich  may  happen  even  in  the  course  of  puncture. 

We  Avill  particularise  these  :  Avounding' of  arteries,  AAiththe 
means  of  aA^oiding  it;  Avhat  should  be  done  in  case  the  puncture 
proAes  negative ;  Avhen  it  causes  bleeding  ;  Avhen  the  cutaneous 
orifice  is  obstructed  b)  granulation  tissue,  after  the  needle  is 
AA ithdraAAu ;  the  course  to  adopt  AA'hen  the  patient  comes  to  you, 
the  skin  being  already  inflamed  and  attenuated,  ready  to  giA^e  Avay . 

1.  Wounding  of  vessels. 

Abscesses  are  sometimes  found  embracing  A^eins  or  arteries  of 
some  size ;  how  do  you  avoid  Avounding  those  vessels  ?  It  Avill  be 
A^ery  simple  —  after  vou  have  cast  your  eyes  OA^er  the  figures 
oppositeand read  their  descriptions,      (fig.  13-,  i38,   139,   i4o). 

2.  The  puncture  is  negative  (no  pus  flows). 

The  needle  is  introduced,  aspiration  is  made,  nothing  appears. 


AVinr    IS    TO    BE    DONE    IN    CASE    OF    NEGATIVE    riNCTIUK.'        I '|() 

\\li\;'  a)  li  iiKiN  1)1'  (luc  Im  llie  faulty  working  of  the 
aspirator.  Make  sure  thai  \ou  have  really  made  a  vacuum 
liv    drawing:  into   the  instrument  a   little  hoiled  Avatcr  iVoni    a 

ha^iii).       Il'a  vacuum  has  iidl   hern  nrdchicfd.  \  ou   should  tiohten 


Fig.   187.  —  How  to  protect  the  vessels  in  the  case  of  a  small  abscess  Iving  over  them 

;in  the  fold  of  the  groin). 

Fig.    1 38.  —  The  abscess  is  pushed  for>yards  by  pressure  of  the  finger. 

The  needle  pushed  in  at  an  angle,  does  not  risk  injuring  the  vein. 

the  two  screws  which  serve  to  regulate  it.  and  aspirate  again. 
But  the  pus  still  does  not  flow. 
Look  for  another  cause. 
h)  Are  you  certain  you  are  in  the  abscess  ?     neither  to  one 


Fig.  109.  —  An  abscess  situated  behind   the  vessels. 

Fig.  lie.  —  A  finger  is  pressed  firmly  on  the  skin  on  the  inner  side  ol'  the  vein  in 
the  direction  of  the  arrow.  The  abscess  is  made  to  protrude  on  the  outer  side  of 
the  artery  :  a  second  finger  protects  the  artery  during  the  puncture. 

side  nor  to  the  other  of  it!'     In  order   to  know   this,   nou   pro- 
ceed, whilst  an  assistant  holds  the   aspirator,  to  make  a  fresh 
palpation   of  the  neighbourhood,  and   ascertain  if  the    level  of 
the  abscess  corresponds  exactly  with  the  point  of  the  needle. 
AA  hen   in  doubt,  push  in  or  withdraw   a  little  the  needle 


l5o  PUNCTURE    OF    ABSCESSES.     POSSIBLE    INCIDENTS 

coupled  on  to   the   aspirator,  you  will  move  about  within   the 
Aacuum  in  the  neighbouring  parts. 

But  if  the  pus  Avill  not  flow  at  all,  it  is  because  : 

c)  Your  needle  is  blocked. 

Generally  one  feels  at  once  that  the  needle  must  be  blocked  : 
because  one  has  the  sensation,  very  plainly,  of  penetrating  into 
a  layer  of  liquid,  or  because  one  has  already  withdrawn  a 
little  of  the  liquid,  when  all  at  once  the  flow  is  stopped  —  in 
spite  of  the  fact  that  one  feels  quite  well  that  the  abscess  is  not 
yet  empty. 

What  can  you  do  to  clear  the  needle? 

There  are  practitioners  who  Avould,  even  in  this  case,  press 
very  firmly  on  the  abscess,  to  evacuate  the  engaged  clot  :  a 
bad  manoeuvre  which  would  cause  bleeding  and  bring  about 
innoculations,  —  the  least  inconvenience  of  this  method  being 
that  it  is  nearly  always  useless. 

You  must,  on  the  contrary,  drive  back  the  clot  into  the 
abscess .  To  do  that,  you  replace  the  aspirator  by  the  syringe,  and 
force  vigourously  into  the  needle  5  or  6  gr .  of  creosote  oil  with  iodo- 
form, or,  better  still,  of  sterilised  water  ;  after  that  Avithdraw  the 
syringe  and  replace  the  aspirator,  and  you  Avill  see  the  floAv  return. 

If  the  needle  become  blocked  a  second  time,  you  might 
force  in  a  new  injection  or  introduce  into  the  mouth  of  the 
needle  the  metallic  brush  (fig.  io6)  of  Avhich  the  length  is  cal- 
culated so  as  not  to  pass  beyond  a  fcAv  millimetres  of  the 
extremity  of  the  needle. 

If  it  is  constantly  being  blocked,  do  not  give  it  up,  do 
not  be  unnerved,  and,  aboA^e  all,  do  not  imitate  those  impa- 
tient surgeons  aa^o  immediately  cut  into  the  abscess,  Avhich 
«  refuses  »  to  be  emptied. 

Too  often,  this  fault,  committed  Avith  a  light  heart,  VA'Ould 
be  irreparable  :  the  fistula  produced  would  never  close.  No. 
Content  yourself  Avith  injecting  3  to  6  gr.  of  naphtol-cam- 
phor  with  glycerin,  then  remove  your  needle,  putting  off  the 
puncture  for  three  or  four  days. 


AMIAT     lO    !)(•     WIIF.N    TIIEIU;    IS    ItLEK  DINf;  :>  jSi 

DiiiliiU  llicsc  few  (l.iNs  (lie  iia|ilil(iUcaiii j)li()i'  will  Iia\c  liail 
lime  lo  solieii  ihc  abscess  conlenls  ;  lliis  time  y(3u  will  obtain  pus. 
If.  lor  some  exiraortlinary  reason,  von  slill  do  not  obtain  il, 
Nou  should  attain  inject  naplilol  Avhicli  will  at  last  produce  a 
liquid  ta])able  of  being  evacuated,  il'  not  by  needle  N'\  o. 
then  by  needle  N°.  [\.  Avhicli  nou  would  be  justified  in  using 
under  the  circumstances. 

3.  There  is  bleeding.  —  You  draw  blood  a\  illi  your  needle 
as  soon  as  it  is  introduced. 

a)  If  it  is  at  the  commencement  of  the  puncture  and  there 
are  merely  a  few  rosy  streaks  in  the  midst  of  the  hquid,  that 
is  nothing;  continue  to  aspirate  without  fear,  and  you  will 
notice  that  at  the  second  aspiration,  no  more  blood  is  obtained, 
but  only  pus. 

h)  On  the  other  hand,  if  immediately  the  needle  is  intro- 
duced, a  jet  of  blood  escapes,  you  may  be  certain  that  you 
have  struck  some  small  vessel  of  the  Avail  of  the  abscess  or  of 
the  surrounding  soft  parts  :  it  Avill  be  better  to  withdraw  your 
needle  at  once,  then  apply  pressure  for  a  few  minutes  Avith  a 
large  tampon  kept  in  position  by  the  hand,  after  Avhich  you 
apply  a  compressive  dressing,  postponing  the  puncture  and 
injection  until  the  next  day  or  the  day  after,  unless  it  is  necessary 
to  empty  the  abscess  immediately,  in  Avhich  case  you  Avill  puncture 
again,  choosing  another  place  for  the  introduction  of  the  needle, 
c)  At  the  end  of  the  puncture,  after  having  emptied  the 
abscess,  if  you  see  that  the  pus  is  slightly  tinged  with  blood, 
the  evacuation  is  sufficient,  make  haste  to  AvilhdraAv  the  aspi- 
rator, push  in  the  injection,  and  AvithdraAv  the  needle.  Here 
again,  you  apply  pressure  for  several  minutes,  then  you  apply 
the  compressiAe  dressing. 

In  all  cases  Avhcre  the  abscess  has  shown  traces  of  blood, 
do  not  be  surprised  at  obtaining  at  the  following  puncture, 
some  blackish  or  grayish  brown  fluid,  it  is  only  a  mixture  of 
pus  and  altered  blood. 


l52 


PUNCTURE    OF    AN    ABSCESS. 


POSSIBLE    INCIDENTS 


But  now  and  then  at  the  time  of  the  puncture  you  with- 
draw a  liquid  of  reddish  or  chocolate  colour  sometimes  blac- 
kish, which  is  blood  more  or  less  altered.  You  know  that 
this  is  from  the  pocket  of  a  cold  abscess  (and  not  from  a  simple 


Fig.   I /(I.  —  The  skin  is  thin  and  inllamed  at  one  point.       You  will  puncture 
by  entering  the  needle  "well  away  from  the  cutaneous  zone  of  the  abscess. 

traumatic  hematoma),  by  its  situation  near  an  articulation  or 
near  a  bone  certainly  tuberculous. 

It  will  be  necessary  to  empty  the  abscess  but  Avilhout 
injecting  anything  at  once,  and  to  apply  a  firm  dressing;  — 
after  that  you  Avill  wait  4  or  5  weeks,  and  even  longer  if 
possible,  that  is,  as  long  as  the  condition  of  the  skin  will 
permit,  before  again  performing  a  puncture. 

4.  The  cutaneous  orifice  is  obstructed  after  removing 
the  needle,  by  a  drop  of  pus  or  some  granulation  debris. 

After  having  withdrawn  the  needle,  you  may  see  a  drop  of 


PLATE  II 


COLD  ABSCESS  READY  TO  BURST 

HOW  TO  SAVE  THE  SKIN?  iSee  explanation  belo-\v  illustration) 


On  her  arrival  at  Berck  this  girl  had  a  cold  abscess"ready  to  burst ;  skin  already  red  and 
very  thin.  In  this  case,  to  save  the  skin  we  made  punctures  every    day   or    every   othei  ■ 
day   (without   consecutive    injections),   during    2   weeks.  On  the    lo^h   ^lay    the   skin    was 
saved,  as  eau  be  seen  in  the  next  plate  (pi.  III). 


PLATE   III 


THE   SAME  (see  pi.  II).  THE   SKIN  IS  SAVED 
(SEE  EXPLANATION  BELOW  THE  FIGURE) 


The  same  child  as  on  plate  II,  alter  i5  days  of  treatment  (puncture  nearly 
every  day, without  injection).  One  sees  here  that  the  skin  is  saved,  it  has 
regained  its  normal  colour.  From  this  time,  we  made  punctures  and 
injections,  i.  e,  the  usual  treatment  for  cold  abscesses. 


Tlir    SKIN     IS    AllOlT    TO    TIltrAK.     WHAT    IS    TO     BE     IjOM:!'     I.').'} 

pus.  or  some  caseous  particles  or  other  debris  from  the  abscess 
wall,  appear  in  the  opening-.  ^  ou  should  remove  the  debris 
^\ilha  tampon  and  wash  tlie  part  with  great  care,  so  as  to 
;i\c>i(|  all  possible  innoculatiun  of  the  skin. 

Alter  all,  this  little  incident  rarely  occurs  if  vou  use  onlv 
a  line  needle,  N"  3,  for  puncture,  and  if  you  oidy  approach 
the  abscess  by  a  long  and  oblique  track,  and  finally  if,  in  the 
case  of  aspiration  without  injection,  you  take  great  care  to 
close  the  valve  before  withdrawing  the  needle  while  joined  on 
to  the  aspirator;  if  you  do  not.  the  vacuum  still  remaining 
^\ill  draw  the  clots  up  to  the  orifice  in  the  skin. 

5.  Incidents  arising  from  the  bad  condition  of  the  skin 
when  the  patient  is  first  seen. 

The  skin  is  reddened  and  thinned  when  first  seen,  this 
means  that  the  deep  surface  of  the  skin  is  already  innoculated 
and  invaded  by  the  tuberculosed  wall  of  the  abscess. 

Can  you  save  the  skin.'^     \es  and  no. 

It  is  not  always  possible  and  it  is  on  account  of  this  that  it 
is  not  permissible  for  the  practitioner  avIio  has  the  patient 
under  observation  from  the  outset,  before  any  alteration  in  the 
skin  has  occurred,  and  who  has  the  choice  of  the  moment  for 
intervening,  it  is  not  permissible,  I  say,  to  postpone  the 
the  first  puncture  beyond  a  few-  days. 

But  if  nothing  is  neglected  this  skin  can  oftentimes,  even 
most  generally,  be  saved.  At  any  rate  this  saving  of  the  skin 
must  always  be  attempted;  the  first  condition  in  order  to  attain 
this  object,  is  to  desire  it.  Now,  most  of  those  who  are  in 
favour  of  puncture  and  injection  believe  as  soon  as  they  seethe 
skin  already  red  and  thin,  that  the  battle  is  lost  beforehand; 
thev  will  not  even  attempt  a  struggle.  Ahorse  still,  they  at 
once  take  the  knife  and  freely  open  the  abscess,  judging  that 
a  surgical  opening  is  better  than  a  spontanecus  opening.  Foo- 
li-li  |)olicy  I 

This  is  quite  wrong,  there  is  no  reason  ever  to  despair  of 
saving  the  skin,  even  when  most  compromised;  especially  is  it 


1 54  PU^JCTLRE    OF   ABSCESS.    POSSIBLE   INCIDENTS 

never  advisable  to  use  the  knife;  it  is  ten  times  preferable  to 
fold  one's  arms  :  if  you  do  not  touch  the  skin  at  all,  it  pre- 
serves at  least  a  slight  chance  of  saving  itself. 

Unhappily,  as  to  this,  practitioners  are  very  difficult  to 
convince,  I  repeat  it,  and  it  happens  every  day  that  they,  Avho 
say  that  they  accept  the  method  of  puncture,  open  cold 
abscesses  or  tuberculous  suppurations,  judging  that  a  in  this 
particular  case  »  (^??),  which  they  have  had  under  their  eyes, 
the  skin  is  already  too  attenuated  aud  too  inflamed  to  allow  of 
their  abiding  strictly  to  the  rule. 

Nay,  this  rule  does  not  admit  of  exception.  One  must 
ahvays  endeavour  to  save  the  integument,  and  one  will  often 
be  successful. 

We  have  cited  a  number  of  facts  in  support  of  that  Avhich 
Ave  advance  here  (see  my  book  Le^  maladies  qii'on  soigne  a  Berck, 
p.   I20,  Masson,  editeur). 

How  to  save  skin  which  is  compromised  ? 

There  are  two  indications   to  fulfil   : 

The  first  is  to  do  away  with  all  tension  of  the  skin  which 
is  so  attenuated  and  offers  so  little  resistance,  and,  for  that,  to 
puncture  the  abscess  every  day ;  the  second  is  to  prevent  the 
march  of  invasion  of  the  tuberculosis,  which  calls  for  injections. 

But  are  not  the  two  indications  contradictory  .►^  If  injections 
are  made,  secretion  by  the  Avall  of  the  abscess  is  encouraged  and 
the  abscess  refills;  but  wdthout  injections,  the  tuberculosis  is 
not  arrested  in  its  march,  it  will  finish  by  destroying  the  skin. 

What  is  to  be  doneP     There  is  an  alternative. 

It  is  to  puncture  the  abscess  every  day,  or  every  other  day 
and  then  to  inject  only  a  very  small  quantity  of  iodoformed 
creosote  oil;  1/2  to  i  c.c.  for  small  abscesses,  3  to  4  gr.  for 
large  ones.  Thus,  you  inject  sufficient  liquid  to  modify  the 
granulations  on  the  deep  surface  of  the  skin,  but  not  enough 
to  excite  a  hyper-secretion  from  the  abscess  wall,  Avhicli  Avould 
still  further  lessen  the  vitality  of  the  skin. 


\\ii\r   T(»   DO   \\iii:n   tiii:   auscess   does   not   ihu    i  I'.'      ij3 

111  siicli  a  (■;!•<(■  (1(1  iiol  neglect,  C\|)('ciall\  if  dcaliiif;-  with 
ail  cKlensive  abscess,  lo  [)lacc  llie  paliciU  in  such  a  position 
thai  tho  inllaiiicd  part  of  the  skin  is  uppermost ;  anIicr  neces- 
sary make  the  palieni  lie  face  downwards,  may-be  for  several 
days  and  several  niglits.  He  soon  becomes  accustomed  to 
this  position,  -which  gives  us,  in  many  cases,  llie  best  results 
in  helping  to  sa\e  a  skin  ready  to  give  way. 

And  as  soon  as  the  skin  has  been  undoubtedly  saved,  return 
to  the  ordinary  treatment  of  the  abscess  by  puncture  and  injec- 
tion, going  up  to  a  series  of  seven  injections,  the  regulation 
number. 

B.  —  CONSECUTIVE   INCIDENTS, 
to  one  or  several  punctures  or  injections. 

There  is  the  skin,  the  resistance  of  which  becomes  lessened 
in  spite  of,  or  even  on  account  of,  treatment.  There  is  the 
abscess  which  does  not  dry  up,  or  which  becomes  infected,  or 
which  bursts  open,  in  spite  of  everything. 

a)  The  skin  becomes  red  and  thin  after  one  or  several  sit- 
tings. One  has  established  that,  alter  each  puncture  and 
injection,  the  abscess  refdls  and  before  long  the  increased 
tension  in  the  abscess  creates  a  danger  to  the  skin.  This 
hvper-secretion  from  the  wall  is  due  lo  an  excessive  reaction 
caused  by  the  injections.  Discontinue  them  then,  for  a  while, 
but  continue  the  punctures,  without  waiting  for  the  lo  to  12 
days  interval  (v.  p.   i45.). 

Repuncture,  were  it  the  day  after  the  preceding  puncture,  and 
puncture  again  every  day  (without  injecting  anything)  until  the 
red  and  thin  skin  has  recovered  its  resistance  and  its  normal  colour. 

At  this  moment  you  start  the  injections  again,  if  the  patient 
has  not  had  the  regulation  number,  but  taking  care  this  time, 
that  you  inject  only  half  or  a  third  of  the  dose  used  before, 
or  make  only  one  injection  for  two  or  three  punctures. 

b)  The  abscess  does  not  dry  up. 

After   having   continued   the  punctures    and  injections    for 


1 56  PUNCTURE   OF   ABSCESSES.     POSSIBLE    INCIDENTS 

two  or  three  months,  the  ahscess  continues  as  large  as  at  the 
commencement  of  the  treatment. 

This  persistance  of  the  abscess  is  due,  most  often,  to  the 
fact  that  too  many  or  not  enough  injections  have  been  made. 
It  is  to  avoid  this  double  stumbling-block  that  it  is  necessary 
to  go  up  to  the  number  of  7  or  8  injections,  but  not  to  exceed 
that.  If  it  is  a  mistake  to  keep  to  one  or  t^YO  injections,  it  is 
a  mistake  also  to  continue  the  injections  as  long  as  the  abscess 
reappears;  it  may  happen  that,  for  a  few  days  after  the  injection, 
the  liquid  does  not  reform,  that  is  the  exception;  most  often, 
the  liquid  reforms  as  long  as  you  continue  the  injections. 

Yes,  even  after  the  wall  of  the  abscess  has  been  thoroughly 
cleansed,  a  fresh  injection  of  the  modifying  liquid,  always  a 
little  irritating,  sets  up  a  secretion  of  serum  from  the  wall  — 
amicrobic  —  a  secretion  Avhich  may  persist  indefinitely,  if 
injections  are  continued  indefinitely. 

The  injections  should  be.  discontinued  after  the  seventh  or 
eighth,  and  from  that  time  make  only  one  puncture  without 
injecting,  then  a  compression  in  the  manner  described,  to  effect 
the  approximation  of  the  refreshed  wall. 

If,  after  two  or  three  weeks  compression,  fluctuation  can 
still  be  felt,  puncture  again  and  recommence  compression  and 
continue  it  for  three  weeks  longer. 

At  the  end  of  that  time,  examine  again.  If  the  abscess 
persists  with  the  same  volume  (or  practically  the  same),  empty 
it  again  and  make  compression  again  for  a  third  period  of 
like  duration.  The  abscess  should  now  be  dried  uj).  If  it  is 
not  so  it  is,  in  this  particular  case,  because  the  wall  of  the 
abscess  has  not  been  sufficiently  modified  by  the  regulation 
number  of  injections. 

Then  you  must  begin  again  a  complete  regular  treatment, 
that  is  a  second  series  of  punctures  and  injections  —  after 
which,  a  last  puncture  without  injection  and  compression. 
But,  not  oftener  than  once  in  ten  times,  will  you  be  obliged 
to  make   thus  a  second  series  of  punctures  and  injections,  and 


Tilt;    ABSCESS    BECOMES    INFECTKD.   WHAT     IS    To    ItE    DONK  1'     l7)- 

nol  oflener  lliaii  once  or  Iwicc  In  a  Imiidrcd,  a  lliird  series. 
On  llic  condition  however  llial  ihe  general  slale  of  llie  patient 
is  not  loi)  bad,  ami  lli.il  ihr  lucal  Irealnicnl  of  llie  causal 
lesion  of  the  abscess  b\  iiravilalion  is  not  loo  defeclive.  For. 
one  or  another  of  these  causes  nia\,  in  fad.  iircvcnl  the  cure 
uf  the  abscess. 

Tlius,  for  example,  you  iiia\  ha\e  fMllnwcd  an  unimpea- 
chable local  treatment  of  liie  abscess,  the  abscess  will  never- 
theless go  on  for  ever,  if  the  patient  be  cachetic,  or  presents 
multiple  tuberculous  foci. 

Or  again,  if  you  do  not  look  Avell  after  the  original  condi- 
tion Avliich  has  caused  the  abscess  (hip  disease.  Poll's  disease, 
while  swelling);  if,  for  example,  you  do  not  put  those  patients 
into  a  position  of  absolute  repose,  if  you  allow  them  to  walk 
about,  and  if  you  do  not  immobilize  them  with  good  apparatus, 
the  abscess  by  gravitation  runs  a  grave  risk  of  never  drving  up. 

And  this  can  be  seen  in  certain  cervical  adenites ;  the  abs- 
cesses persist  as  long  as  the  bad  condition  of  the  mouth  and  of 
the  tributary  territories  of  the  glands  causing  the  abscess  continues. 

And  from  that  the  treatment  can  be  guessed.  It  is  to 
suppress  the  causes  which  are  producing  the  suppuration,  to 
seek  for  every  means  that  will  ameliorate  the  general  condition 
of  the  patient,  to  prevent  walking,  to  immobilize  him  w ith  a 
good  plaster,  to  remove  teeth  a\  liich  are  decidedlv  bad  or  not 
absolutely  sound,  etc. 

c)  Infection  of  the  abscess  occurring  in  the  course  of 
treatment. 

May  we  hope  that  after  our  numerous  recommendations,  no 
one  will  ever  make  a  mistake  in  asepsis  in  the  course  of  punc- 
ture and  injection?  and  that  you  will  always  know  hoAv  to 
avoid  infection  of  the  abscess. 

Alas,  no!'  Errare  hiimanuin  est! 

It  is  necessary  then  to  give  here  a  sketch,  a  symptomatic 
table  (to  which  we  shall  return),  of  super-added  septic  infection. 

The   most    important    sign  of  infection,  is   the   appearance 


1 58  PLJJCTLRE    OF    ABSCESSES.    POSSIBLE    INCIDENTS 

of  evening   fever   with   marked   morning  remission.     And 

this   fever    is   accompanied  by    the    general   phenomena    with 
Avhich  Ave  are  familiar:  loss  of  appetite,  rapid  wasting,  insomnia. 
There  are  also  local  changes  in  the  abscess  and  in  the  parts 
around. 

These  local  changes  present  themselves  under  tAvo  different 
aspects  : 

a)  Sometimes,  they  present  a  rapid  transformation  from 
a  cold  abscess  to  an  acute  phlegmon  ;  there  appear  redness, 
heat,  local  SAvelling,  and  pain,  either  spontaneous  or  on 
pressure.  Before  long,  the  inflamed  skin  tends  to  ulcerate  and 
give  way  at  a  point  whence  issues  a  thick,  phlegmonous,  vis- 
cid, microbe-laden  pus,  which  must  not  be  mistaken  for  the 
non-microbic  pus  of  an  abscess  produced  by  our  solvent  injec- 
tions, or  by  oil  of  turpentine  when  one  wishes  to  produce  a 
stationary  abscess.  Here  are  the  means  of  making  a  diagnosis; 
in  the  aseptic  abscess,  the  temperature  falls  under  the  efifect 
of  repeated  punctures  not  followed  by  injections,  in  the  septic 
abscess  the  temperature  does  not  yield  until  after  the  opening 
and  draining  of  the  abscess. 

b)  The  other  case  is  where  there  are  little  or  no  appreciable 
changes  in  the  skin  :  it  applies  generally  to  deep  abscesses ; 
at  the  same  time,  the  general  phenomena  predominate,  but  the 
contents  of  the  abscess  has  changed  ;  it  is  no  longer  true  pus, 
but  a  saiigiilnolent  liquid,  the  colour  of  tomato  or  of  wine  lees ; 
it  contains  sometimes  gaseous  bubbles  and  often  exhales  a 
fetid  odour. 

Treatment.  —  One  endeavours,  by  means  of  daily  punc- 
tures (without  injection),  to  make  the  temperature  fall.  —  If 
the  infection  is  very  slight,  one  can  do  this.  It  is  rare,  but  I 
have  seen  it;  then,  attempt  it. 

If,  in  spite  of  punctures  made  nearly  every  day  for  a 
certain  time  —  fifteen  days,  for  example  —  fever  persist;  if 
moreover  you  are  certain  that  the  fever  is  not  to  be  attributed 
to    any    intercurrent    malady    or    to  a   visceral   localization    of 


ABSCESSIS     \l\\     Iti:    IMECTCD    AT    THE    OLTSICT  I  .')i^ 

luhen-ulosis,   llien.    recognise  lliat  }oii  have  no  alternative   l)iil 
to  o[)oii  the  abscess.      Accept  the  inevitable. 

^nu  iimsl  know  also  llial  M)U  shoultl  not  tielav  the  openiti'', 
for  W  you  wail  too  lonfi',  the  liver  and  (he  kidncNs  run  the 
risk   of  becoming  infccled.  and  that  visceral  infection  will  be 


Fig,   i-'i2.  —  The  skin  very  much  stretched  by  pus  causing  it  to  give  wiiy 
at  a  point. 


capable,  later  on.  of  spreading  on  its  OAvn  account,  even  after 
the  abscess  has  been  opened. 

Therefore,  if  after  lo  or  20  days,  the  phenomena  of  infection 
and  fever  have  not  disappeared,  resign  yourself,  open  the 
abscess  and  drain  it  well.  And  you  Avill  behave  afterwards, 
as  you  would  in  dealing  with  an  infected  fistula. 

Are  there  not  abscesses  infected  from  the  very  outset, 
infected  before  having  been  interfered  with.' 

^es,  but  exceptionally,  in  the  two  following  cases; 


l6o       PUNCTURE    OF   ABSCESSES.   AVILVT    TO    DO   IF    THE   ABSCESS   OPENS? 

First  case.  —  That  of  an  iliac  or  lumbar  abscess  of  Pott's 
disease,  Avhich  may,  strictly  speaking,  be  infected  at  the  outset 
by  the  contiguity  of  the  intestine,  fissured  or  not. 

This  may  happen  perhaps  once  in  a  hundred  times,  and 
even  here,  in  these  abscesses,  the  infection,  when  it  exists, 
comes,  99  times  out  of  a  loo,  from  Avithout,  from  a  fault  in  the 
asepsis,  or  from  a  fissure  in  the  skin. 


Fig.   i43.  —  The  abscess  Las  opened  extensively.      A  patcli  of  skin  has  given  way. 

The  signs  of  infection  and  it's  treatment  are  the  same  as 
those  given  above. 

Second  case.     This  relates  to  suppurative  adenitis  in  the  neck. 

When  there  are  bad  teeth,  erosions  of  the  pharynx,  or  of 
the  ears,  or  of  the  nose,  or  of  other  tributary  territories  of  the 
cervical  glands,  one  cannot  be  sure  of  being  able  to  prevent,  with 
certainty,  the  rupture  of  the  skin  near  a  tuberculous  abscess, 
because  then,  in  many  cases,  it  is  no  longer  a  question  of 
tuberculous  abscesses,  but  of  abscesses  infected,  little  or  much, 
by  septic  germs  coming  from  without. 

Therefore,  here  again,  make  some  reservations  as  to  the 
chances  of  saving  the  skin,  if  you  have  seen  ulcerations  of  the 


now    i<)  ci.osK  AN    viiscr.ss  which  has  oi'Knkd  si'omamcoi  si,\    iGi 

pliai'Mix.  It'clli  had  oi- iiol  absoltileiN  sound,  rlc.  The  iiitcction 
iiiav  1)0  llieu  yravc  eiioiiyii  to  lead  lo  a  bursting  of  llic  skin,  and 
al  the  same  lime,  not  sufficiently  so  lo  cause  lever,  or  at  least  a 
fever  of  more  than  a  lew  tenths  of  a  degree. 

d)  Spontaneous  opening  of  the  abscess. 

We  have  mentioned  above  tlie  case  where  the  rupture  of  the 
skin  Avas  threatening.  Imagine  the  case,  still  more  unfavo- 
rable, where  the  opening  has  been  produced  at  the  moment  of 
the  patients  arrival,  or  a  little  before,  or  even  before  your  eyes, 
in  the  course  *  of  treatment,  after  one  or  scA^eral  injections. 

What  is  to  be  done  ? 

Here  again,  try  and  retrieve  the  condition  of  things.  Ins- 
tead of  enlarging  the  opening,  as  alas!  so  many  surgeons  do, 
you  should  do  everything  possible  to  close  it.  —  and  you  avIH 
generally  succeed. 

You  will  succeed  especially  w  hen  the  opening  has  not  taken 
place  until  after  a  certain  number  of  injections,  because  then 
the  deep  part  of  the  abscess  has  had  a  good  chance  of  being  so 
modiQed  and  refreshed  that  the  cicatrisation  may  be  brought 
about  regularly  and  quickly,  from  the  deepest  part  to  the  peri- 
phery, (the  small  superficial  wound  being,  in  this  case,  no 
longer  nurtured  by  the  abscess).  The  chances  of  success  are 
decreased,  one  can  understand,  if  no  injections  have  yet  been 
made,  but  you  may  still  succeed  here  A'ery  olten. 

How? 

I.  For,  in  fact,  it  may  happen  (and  though  the  case  be  rare,  I  ouglit  lo 
mention  it)  tliat.  in  such  patient,  even  when  seen  in  time,  with  skin  still 
sound,  even  treated  regularly,  and  without  there  having  been  any  fault 
committed  in  the  technique,  it  may  happen  that  the  tuberculosis  is,  in 
this  case,  particularly  malignant,  that  it  has  been  impossible  to  arrest  its  pro- 
gress towards  the  skin,  and  that  the  skin  gives  wav ;  the  abscess  is  open,  a 
small  fistula  has  been  produced.  But,  be  re-assured,  such  evil  cases,  tuber- 
culoses so  malignant,  are  scarcely  ever  met  with,  say  once  or  twice  in  a 
hundred  cases. 

It  still  remains  true  that  with  good  general  treatment  and  punctures  well 
performed,  you  may  promise  a  cure  of  abscesses  «  without  a  hitch  ». 

Calot.  —  Indispensable  orlhopedics.  ii 


l62  PUXGTURE    OF    ABSCESSES.     POSSIBLE    INCIDENTS 

By  simple  methods ; 

This,  for  tuberculous  wounds;  daily  dressings,  thoroughly  aseptic,  or 
applications  of  various  topical  remedies,  tincture  of  iodine,  oxygenated  water, 
permanganate  of  potash,  naphtalan,  Championniere  poAvder,  our  own  pow- 
der, a  drop  of  lactic  acid,  iodoformed  oil  and  creosote,  ^  igo  plaster,  neol,  etc. 

Take    care    to  change  the  remedy  nearly   every   day,   for  2  or  3  weeks. 

Here  is  the  formula  of  our  powder  : 

Aristol 4o  grammes. 

Subnitrate  of  Bismuth 100         — 

Grey  Quinine,  pulverised 3oo         — 

Siamese  Benzoin,  pulverised 3oo          — 

Carbonate  of  Magnesia 3oo         — 

Oil  of  Eucalyptus 3o 

After  2  or  3  weeks  : 

Either  cicatrisation  has  been  accomplished.  In  that  case, 
if  the  abscess  is  no  longer  perceptible,  the  treatment  is  finished. 
If  the  abscess  persist,  you  will  treat  it  by  punctures  and  injec- 
tions, after  having  waited  a  few  days  longer,  to  give  the  skin 
time  to  strengthen  itself. 

Or  else  cicatrisation  has  not  occurred,  nor  anything  like  it, 
that  is  the  small  wound  is  kept  open  by  a  persistent  abscess;  it 
can  be  closed  only  by  dealing  directly  with  the  abscess.  For 
this  one  makes  in  the  track,  and  in  the  cavity  of  the  abscess,  some 
modifying  injections,  either  in  liquid  form,  or  in  the  form  of  paste. 

The  medicated  agents  are  the  same  as  for  the  treatment  of 
a  cold  abscess. 

If  injections  of  creosote,  of  iodoform,  of  naphtol  camphor 
with  glycerine,  cure  the  tuberculogenous  wall  of  a  closed  cold 
abscess,  it  is  not  logical  to  demand  of  those  injections  the 
cure  of  the  tuberculogenous  wall  of  open  abscesses,  of  cavities, 
or  of  fistulous  tracks ;  the  anatomical  and  bacteriological  consti- 
tution of  the  wall  is  identical  in  both  cases,  so  long  as  they 
have  not  been  penetrated  through  the  open  orifice  by  septic 
germs    entering  from  the  exterior. 

Nevertheless,  even  when  not  infected,  the  open  abscess  is 
not  in  the  same  condition  as  the  closed  abscess,  its  cure  is  not 
so  easy,  for  two  reasons; 


AMIAT    TO     DO    IN    THE    CASIC    OK    THE    ABSCESS    OPEMNO  lG3 

Tlie  first  is  dial  the  open  abscess  constantly  runs  tlic  risk 
of  infection. 

Tlie  second  is  thai  tlic  injecletl  liquid  being  not  retained, 
returns  immediately  —  without  having  time  to  modify  tlie  wall 
of  the  abscess.  Compare  with  this  case  that  of  a  closed  abscess, 
where  the  injection  is  acting  day  and  night,  for  several  weeks. 

Fortunately,  we  are  able  to  put  an  end  to  this  double 
difficulty;  i"",  by  means  of  a  very  severe  asepsis,  we  can 
prevent,  at  least  for  a  certain  time,  the  entry  of  septic  germs 
from  without. 

2'"'.  In  the  second  place,  the  modifying  liquid  may  be  retained 
in  the  sinus  and  in  the  cavity.  This  result  is  obtained  by  closing 
the  orifice  (immediately  the  injection  has  been  pushed  in),  by 
means  of  a  conical  plug  of  sterilised  avooI  introduced  into  the 
opening,  or  more  simply  by  a  small  tampon  (of  wool)  applied 
over  it,  and  pressing  on  the  cutaneous  lips  of  the  fistula,  —  the 
plug  or  tampon  being  held  afterwards  by  a  few  turns  of  Yelpeau 
bandage. 

S"'.  If  you  do  not  succeed  in  keeping  the  liquid  in  its  place 
by  this  method,  there  still  remains  the  employment  of  the 
same  medicaments  in  the  form  of  paste. 

These  pastes  are  liquified  (by  warming  to  fib"  or  oo")  a 
short  time  before  injection,  and  they  solidify  at  the  temperature 
of  the  body  very  soon  after  being  injected. 

We  will  return  to  the  details  of  this  technique  a  little  fur- 
ther on,  a  propos  of  the  treatment  of  fistula?  not  infected  (v.  p. 
170  and  following). 

The  cure  of  the  cavity  of  the  abscess  and  of  the  sinus  will  lead 
to  that  of  the  small  cutaneous  fistula  which  they  keep  up,  and  cure 
is  the  rule  in  the  recent  fistula?  of  which  we  are  now  speaking, 
occurring  in  the  course  of  treatment  (by  punctures) ;  for  there 
is  here  as  yet  no  infection  or  hardening  of  the  track. 

The  cure  is  consequently,  much  easier  to  obtain  than  in 
old  fistula?. 


11 


THE  TECHNIQUE  OF  INJECTIONS 
IN  THE   DRY  OR  FUNGATING  TUBERCULOSES 

Wc  will  describe  elsewhere,  in  ihe  chapters  devoted  to 
cervical  adenitis,  epidydimitis,  white  swellings,  osteitis,  etc., 
that  is,  a  propos  of  each  dry  or  fangating  tuberculosis,  in 
which  cases  the  injection  ought  to  be  made. 

Here,  Ave  will  only  describe  the  technique  of  the  treatment. 

TECHNIQUE   OF    THE    INJECTIONS 

A.  Instrumentation. 

a)  The  syringe,  of  ordinary  glass  (v.  p.   121). 

b)  Needles  N"'  i  and  2  ;  Number  one  for  very  fluid  liquid, 
number  two  for  more  viscid  liquids. 


Fig.  i/j/i.  —  Needle  n"  i.  Fig.  i/i5.  —  Needle  ii°  2, 

B.  The  liquids. 

These  are  the  same,  in  a  general  Avay,  as  for  cold  abscess, 
namely ; 

a)  The  mixture  of  creosote,  oil,  and  iodoform,  which  is 
((  hardening  »  in  its  action. 


vur.   n.iKCTiONS  in  dry  tlherc  hoses  i05 

b)  The  niixliiic  of  luiplilol,  camphor  and  frlycerinc,  A\liicli 
is  «  softening  ». 

Verv  much  llie  same  doses  arc  used  here  as  in  the  treat- 
ment of  cold  abscess. 

There  is  anotlier  softening  agent,  3  or  6  times  as  active  as 
ihenaphlol  camphor  and  glycerine  ;  it  is  a  mixture  ofequal  parts  of 
the  four  folloxAing  liquids:  sulphoricinated  phenol,  camphorated 
phenol,  camphorated  naphtol,  spirit  of  turpentine.  AA  e  will 
describe  the  indications  a  little  further  on,  p.   i68. 

The  Technique 

One  endeavours  to  effect,  either  the  hardening  of  the  fungo- 
sities,  or  their  *"o/'/f/?/nr^  (after  which  one  will  puncture  them)'. 

a)  To  produce  hardenin<j,  inject  the  mixture  of  oil,  creosote 
and  iodoform  (the dose  from  2  to  8gr.  accordingas  the  patient  be 
infant  or  adult);  make  the  injection  in  the  centre  of  the  funga- 
ting  mass,  and.  in  the  case  of  arthritis  into  the  joint  cavity  itself. 

Repeat  the  injections  every  six  or  seven  days  up  to  a 
maximum  of  10  injections. 

Then,  compress  the  region  with  pads  of  cotton  wool  kept 
in  position  by  ^  elpeau  bandages. 

Note  that  the  hardening  looked  for  is  not  produced  either 
during  the  period  of  the  injections,  nor  immediately  afterwards. 
On  the  contrary,  the  injected  parts  swell  during  that  time;  this 
you  must  warn  the  parents  of. 

It  is  not  for  three  or  four  Aveeks  after  the  tenth  or  last 
injection,  that  the  fungosities  commence  to  diminish  in  size ; 
and  it  is  only  3  or  5  months  after  ceasing  the  injections  that 
you  will  observe  the  disappearance  of  the    tuberculous   masses. 

I.  This  idea  of  the  softening  of  liard  tuherculoses,  for  their  subsequent 
puncture,  appears  now  quite  natural.  But  when  we  first  proposed  it  some 
twenty  years  ago,  anathema  was  thrown  at  us.  Just  think:  «  To  Avant  to 
cause  tuberculoses  to  suppurate  III  ^^  as  tliere  ever  anything  so  monstrous  I..  » 
Today,  my  former  opponents,  and  their  pupils,  constantly  apply  my  method 
and  describe  it forgettinir  of  course  to  mention  mv  name. 


i66 


THE    INJECTIONS    IN    TUBERCULOUS    FUNGOSITIES 


b)  To  obtain  softening.  —  Inject  the  mixture  of  naphtol 
camphor  and  glycerine,  in  a  dose  of  from  3  to  8  gr.  according 
to  the  age  of  the  patient. 

In  this  particular  case,  the  injection  should  be  repeated 
every  day  until  the  softening  has  begun. 

It  is  on  the  fourteenth  or  fifteenth  day  (after  /i  or  5  or 
6  injections)  that  you  begin  to  perceive,  in  the  centre  of  the 
mass,  or  in  the  culs-de-sac  of  the  injected  joint  if  you  are 
treating  an  arthritis,  a  sensation  of  elastic  resistence,  or  even  of 
free  fluctuation  announcing-  the  fact  that  softening  has  occurred. 
From  that  time,  you  puncture  and  in- 
ject, but  extending  the  intervals  between 
the  sittings,  not  making  more  than  one 
each  Aveek. 

\  ou  will  go  up  to  7  or  8  punctures  and 
injections  (counting  from  the  day  when  the 
softening  was  obtained). 

In  a  word,  one  proceeds  here  practically 


Fig.  iZi6. —  The  liquid 
produces,  in  the  cen- 
tre, a  cavity  which 
increases  gradually , 
ty  successive  soften- 
ing of  the  layers  of 
the  tuberculoma. 


as  if  one  were  dealing  with  a  tuberculosis 


suppurated  at  the  onset. 

If  there    still   remain  here    and    there 

small  indurated  points,  they  need  not 
detain  you,  for  they  will  disappear  eventually,  in  the  course 
of  the  progressive  contraction  of  the  injected  tissues,  a  contrac- 
tion which  continues  for  a  very  long  time. 


Which  ought  one  to  seek  for?  Hardening  or  softening? 

Softening  is  better  on  principle,  for  it  leads  to  the  complete 
expulsion  of  the  tuberculous  products  out  of  the  organism, 
whence  the  cure  is  more  certain  and  more  definite.  But,  on 
the  other  hand,  the  inflammatory  reaction  set  up  by  the  soften- 
ing injections  is  notably  more  marked ;  it  is  sometimes  even 
a  little  painful,  although  in  patients  who  are  faint-hearted 
and  in  no  hurry,  such  as  the  children  of  the  upper  classes, 
I  would  advise  you  to  begin  the  injections  of  oil,  creosote  and 


TO    INJECT    llAUnF-MNG.     OU    llETTI-R,     SOFTEMNG    SOI.ITIONS         I  (j- 

iodoloriu.  wliicli  niay  sulficc,  and  even  liave  70  cliances  in  100 
of  suflicing  :  —  except,  in  llie  case  where,  lour  iiionlhs  later, 
the  cure  has  not  hecn  ohtaincd  thus,  one  has  recourse  then  to 
the  soUi'Miii^;'  iiijoiiions  ol  caiiiphoratrd  najtlilnl. 

Or  again,  )0u  could  adopt  tlie  following  formula  : 

For  tuberculoses,  recent,  and  of  benir/n  appearance,  try  har- 
dening (injection  of  oil,  creosote  and  iodoform). 

For  old  tuberculoses  of  grave  appearance,  try  softening 
(injection  of  camphorated  naphthol). 

I  have  just  pointed  out  the  reaction  produced  hy  the  in- 
jections in  the  dry  or  fungating  tuberculoses. 

This  reaction  is  desired.  It  is  necessary.  Its  object  is  to 
transform  the  chronic  inflammatory  process  produced  by  the 
bacillus  into  a  subacute  or  even  distinctly  acute  inflammatory 
process. 

Therefore,  the  injections  bring  about,  or  ought  to  bring 
about,  an  inflammation,  slight  or  intense.  It  is  slight  with 
the  oil,  creosote  and  iodoform,  it  is  more  active  with  the 
naphtol,  camphor  or  the  sulphoricinated  phenol.  It  depends 
also  on  the  dose  of  liquid  injected  and  the  greater  or  less  fre- 
quency of  the  injections. 

Let  there  be  no  misunderstanding  :  it  is  not  of  the  imme- 
diate reaction  that  I  am  speaking  here;  for  Avith  our  liquids, 
the  reaction  is  nil  or  insignificant,  whilst  with  iodoform  and 
ether,  it  is  very  active,  and  with  zinc  chloride  it  is  very  pain- 
ful, even  agonizing,  for  several  hours. 

No,  I  wish  to  speak  of  the  reaction  of  tomorrow  and  the 
day  after.  A  reaction  looked  for,  I  repeat,  a  welcome  reaction, 
since  Ave  wish  for  nothing  less,  with  the  naphthol  camphor 
and  our  softening  mixture,  for  example,  than  to  transform,  in 
a  few  days,  into  a  liquid  state,  solid  and  sometimes  very  hard 
tuberculous  masses.  It  is  evident  that  this  cannot  occur 
without  symptomatic  manifestations  which  accompany  the  for- 
mation of  an  acute  abscess,  or,  at  least,  a  «  tepid  »  abscess. 
Above   all  things  never   forget  to  forewarn   the  parents  or 


1 68  THE  OJECTIONS  O  DRY  TUBERCULOSES 

those  interested,  of  the  early  appearance  and  need  for  this 
local  and  general  reaction,  without  Avhich  you  will  expose 
yourself  to  reproach  or  even  find  yourself  refused  permis- 
sion to  continue  the  treatment;  Avhilst  if  they  are  forewarn- 
ed, they  will  fnid  all  this  quite  natural  and  very  satis- 
factory, since  reaction  is  the  herald  of  the  approaching 
softening  of  the  fungosities  and  of  the  success  of  the  treat- 
ment. Still,  it  is  necessary  that  the  inflammation  should 
not  pass  a  certain  point,  beyond  which  it  would  be  very 
painful.  The  ideal  is  to  reconcile  everything,  to  liquify 
the  fungosities  without  fatiguing  the  patient,  Avliich  is  what 
happens  generally,  if  you  keep  to  the  doses  and  the  intervals 
indicated  above  (v.  p.   i65). 

If,  in  some  patient,  the  reaction  obtained  after  the  first 
injections  is  not  sufficient,  increase  the  dose,  or  lessen  the 
intervals  between  the  injections.  If,  on  the  contrary,  the 
reaction  obtained  from  the  beginning  is  more  intense  than 
would  be  desirable,  reduce  the  dose  to  be  injected  and  allow 
more  time  to  elapse  between  two  injections. 

The  indications  and  method  of  employment  of  the 
other  softening  agent  for  tuberculous  lesions. 

To  obtain  softening  in  fungous  arthritis,  we  use  as  a  rule, 
naphtol,  camphor  and  glycerine.  This  mixture  is  an  excellent 
one,  but  acts  only  Avhen  injected  in  considerable  quantity, 
3  to  8  gr.  as  we  have  said,  in  the  treatment  of  arthritis,  where 
the  injection  is  made  into  a  joint  cavity,  but  it  is  not  so  in 
the  case  of  a  small  cervical  gland,  where  one  cannot  inject  the 
necessary  5  or  6  gr.  of  liquid,  nor  even  3  or  4  gi'- 

In  that  case,  in  order  to  soften  a  hard  adenitis,  it  is  better 
to  use  a  liquid  active  even  in  a  very  small  quantity.  Such  is 
the  mixture  of  equal  parts  of  sulphoricinated  phenol  (20  per 
cent,  20  parts  of  pure  phenol  to  80  of  sulforicinate  of  soda), 
of  camphorated  phenol  and  naphtol  and  spirit  of  turpentine. 


oru   s()i-TEM>(;    Mi\i  I  hi: 


1G9 


0  or  S  (li(i|)s  (if  ihis  liquid  are  siiHlciriil  lo  cffccl  ihc  sof- 
leniiii;'  oi'  llic  Liland.      This   is  Ik^n    \oii  ^\ill  use  il  : 

In  joe  I  (t  or  8  dro[)s  inlo  llic  centre  of  the  filand  or  luhcr- 
onlous  mass. 

It',  alter  2/1  hours^  the  reacliou  which  follows  the  injeclion 
is  very  active,  if  there  is  distinct  local  pain,  insomnia,  fever 
above  38",  keepto  this  one  injection.  On  the  other  hand,  if  the 
reaction  is  ahnost  nil,  again  inject  6 or  8  drops  of  the  mixture 
next  day  or  the  day  after;  this  time  the  injection  will  be  nearly 
always  sul'licienl  to  produce  softening.  You  have  only  to 
wait  until  the  softening  has  taken  place,  Avhich  you  recognise 
by  tbe  appearance  of  fluctuation,  perceptible  at  the  end  of 
three  or  four  days. 

Then,  you  puncture ;  you  withdraw  a  viscid  pus,  the 
colour  of  mahogany. 

If  the  skin  is  reddened,  do  not  repeat  this,  Avait  before 
making  another  injeclion,  until  the  skin  has  become  normal. 
If  the  skin  is  not  reddened,  inject  again,  but  this  time  with 
naphtol,  camphor  and  glycerine;  and  repeat  the  puncture  and 
the  injection  (of  naphtol,  camphor  and  glycerine)  every  four 
days;  you  thus  make  6  or  7  punctures,  with  or  Avithout  injec- 
tions, according  as  the  skin  is  normal  or  reddened.  After  the 
6th  or  7th  puncture,  you  make  a  last  jnmcture,  this  one 
Avithout  consecutiA^e  injection,  and  then  apply  pressure.  In  a 
Avord,  you  proceed,  as  in  the  treatment  of  an  ordinary  cold 
abscess.  If,  tAvo  or  three  Aveeks  later,  there  still  remains  a  cres- 
cent of  gland,  unaffected  by  the  injection,  recommence  the 
injections  of  softening  mixture,  and  carry  on  this  second  treat- 
ment like  the  first,  Avilh  the  double  purpose  of  softening  the 
fungous  mass  and  preserving  the  skin. 

It  is  needless  to  go  on  fighting  against  the  small  remaining 
vestiges  of  the  tuberculous  mass ;  they  Avill  disappear  in  due 
course,  by  themselves,  by  a  process  of  hardening. 


Ill 


THE   TECHNIQUE   OF    INJECTION    IN   THE  TREATMENT 
OF  TUBERCULOUS    FISTULy€ 

We  shall  study,  p.  229,  the  respective  values  of  the  diffe- 
rent treatments  of  tuberculous  fistula?;  surgical  operations, 
expectancy,    physiotherapeutic  methods,     sea-air    baths,   salt- 


Fig.   1A7  to  i5o.  —  Our  different  models  of  nozzles  for  injecting  into  fistulous 
tracks  of  different  shapes. 

baths,    or    sulphur    baths,   sun-baths,  radio-therapy,  radium- 
therapy,  modifying  injections. 

We  shall  see  that  of  all  these  treatments,  the  last  is  ever  so 


INJEcriONS    IN    TUBEUCULOUS    FISTUL.E 


171 


much    (he   best,  and  we  will  Icll  you  Avhyit  is  llie  besl.  Here, 
we  will  speak  only  ol"  the  technique  of  these  injections. 


Fig,  i5i.  —  Nozzle  \iilh  a  cup-shaped  extremity  for  emptying. 

Substances  for  injection. 

Is  there  anything  Avhich  has  not  been  injected  into  tuber- 
culous fistuhe,  from  the  Villattes-liquor  of  our  grand-fathers 
to  the  pommades  so  much  lauded  in    our  own   days,  passing- 


Fig.   162.  —  The  syringe,  in  glass,  mounted  with  its  nozzle. 

by  the  injections  of  boiled  sea-water,  dilute  tincture  of  iodine, 
weak  solution  of  zinc  chloride,  tincture  of  aloes,  etc.? 

Well,  I  have  tried  all  those  injections.  And  after  having 
tried  them  all,  I  have  come  back,  always,  to  our  injections  of 
oil,  creosote  and  iodoform,  and  naphtol  camphor  and  glycerine. 
Clinical  experience  brought  me  back  to  them;  but  reason 
demonstrated  beforehand,  that  these  liquids,  already  recognised 
as  the  best  for  purifying  the  wall  of  cold  abscesses  sliould  also 
be  the  best  for  purifying  the  fungous  wall,  almost  identical,  of 


TUBERCULOUS    FISTULE 


tuberculous  fistulae.  These  medicated  agents  are  employed  in 
fistulee  under  the  same  form,  cold  liquid,  as  in  abscesses, 
Avhenever  the  anatomical  disposition  of  the  orifice  and  of  the 
cavity  allows  of  the  liquid  being  retained  in  place. 

This  is  how  to  proceed. 

Make,  through  the  orifice  of  the  fistula,  Avith  an  ordinary 
glass  syringe  furnished  AA-ith  a  nozzle  of  the  length  and  form 
appropriate  to  the  track,  au  injection  of  4  to  lo  gr.  of  one  of 
the  tAAO  solutions  mentioned;  block  the  orifice  immediately 
afterAAards,  either  AAith  a  small  cone  of  absorbent  cotton  avooI 
forming  a  plug,  introduced   into   the   orifice  of  the  fistula  to  a 


Fig.   1 53.  —  Glass  and  ebonite  syringe  for  the  treatment  of  fistulas  (-which  can 
be  used  in  the  absence  of  the  glass  syringe  of  Collin  or  of  Luer). 

depth  of  2  or  3  cm.,  or,  simply  AA'ith  a  tampon  of  cotton 
Avool,  AAhich,  placed  flat  OA-er  the  orifice,  pushes  the  lips  gently 
iuAAards  —  depresses  them,  in  such  a  AAay  as  to  preA-ent  the 
escape  of  the  fluid  introduced;  if  there  are  seAxral  orifices,  an 
assistant  blocks  in  the  same  manner  the  other  orifices  AA^th 
small  conical  plugs  of  avooI  or  small  tampons. 

All  these  tampons  are  kept  in  position  by  a  \elpeau  bandage 
carefully  applied . 

The  day  after  the  next,  giAe  another  injection,  and  so  on 
CA-ery  other  day. 

Each  time,  remoA'C  the  tampon,  or  the  small  conical  plugs, 
and  alloAA-  the  cavity  to  empty  :  then  inject  again. 

If  the  orifice  is  gaping,  if  the  daily  introduction  of  the 
syringe  and  the  contact  of  a  more  or  less  irritating  liquid 
increases  the  aperture  too  much  for  the  liquid  to  possibly 
remain  in  its  place,  it  is  adAantageous  to  suspend  the  injection 
for  a  feAv  days,  Avhich  will  alloAv  the  orifice  to  contract  a  little. 


NAIUUE    AND     lEClINKJl  E    OF    HIE    INJECTIONS 


it3 


finds  the  track    between  Ihe  swollen 
tissues  around  the  orifice  of  the  fistula. 


Toward  llic  twonly-fifth  day,    llial  Is.  afler  about   lo  injec- 
tions,   tlio    active  wall    is  siiflicienlly   modilied    and    relVcshcd 
to  allow   of  their  closing  and  to 
reckon   npon    the    union    of   llie 
Avail  of  the  tract. 

This  union  is  assisted  by 
compressing  the  parts  with 
small  bands  of  cotton  wool 
placed  cross-wise  and  held  firmly 

by  Yelpeau  bandage.  This  is  Fig.  i5'i.  —  The  nozzle  of  the  syringe 
not  always  easy  (in  the  case 
of  inguinal  fistula  in  Pott's 
disease,  for  example) ;  but  it  is  done  whenever  possible. 
If  adhesion  of  the  two  walls  is  not  obtained  at  ihe  first 
attempt,    if  after   20   days,    during    Avhich    compression   must 

be  kept  up,  there  is  still  an  oozing, 
it  is  necessary  to  recommence  a  ucav 
series  of  from  8  to  10  injections, 
]iroceeding  as  before. 

This  second  series,  followed  bv 
compression  and  a  second  period  of 
waiting,  heals  another  group  of 
listulfe. 

If  the   fistula  is  still   not    cured, 
I  advise  you  to  wait   3  or  4  months 
before  making  further  injections. 
During  these    3  or  4  months  of 
Fig.  i55.  —  intra-fistulous  injec-   simple  ascptic  dressings,  and  of  rest, 
^ion     A  strip  of  damp  cotton   especially  at   the   sea-side  or  in   the 

wool  IS  rolled  round  the  nozzle  ^  "^ 

of  the  syringe ;  the  left  hand  of  country,    the    fistulae    close    at    last, 
tlie  operator  firmly  compresses   nearlv  alwavs,  evcn   thoush   thev  be 

the  wound    with    the   tampon,  ■■  "^    _  '-  "^  _ 

whilst  the  right  hand  removes   Connected    Avitli    bone    Or    a    joint, 

the   syringe    immediately  after    provided     that     One     is     dealing     Avith 
the  injection  is  completed.  ^^  _  '- 

fistula?  not  infected  (no  fever  and  no 
albumen  being  present)  (v.  p.  2  25). 


1-^4  TUBERCULOUS    FISTUL/E.    INJECTIONS 

With  a  little  experience  and  precaution,  you  succeed,  by 
means  of  the  conical  plugs  of  cotton  wool  or  tampons,  in  re- 
taining the  liquids  in  many  fistulous  tracks. 

But  with  most  fistulre,  it  is  not  so;  the  orifice,  or  orifices, 
are  gaping  too  much  to  alloAv  us  to  completely  close  them 
with  the  conical  plugs  or  tampons  of  wool,  and  to  retain  com- 
pletely the  liquid  in  the  fistulous  tracks.  In  that  case,  it  is 
necessary  to  incorporate  the  active  substances  (creosote,  iodoform. 


Fig.  i56.  —  Communicating  fistula3.  The  injection  is  pushed  into  one  of  the  listu- 
laj,  while  tlie  left  hand,  in  order  to  keep  the  injected  liquid  in  its  place,  blocks 
the  other  fistula  or  fistulae  by  means  of  a  large  tampon. 

naphtol,  or  camphorated  phenol)  with  a  paste  which  will 
dissolve  in  a  water-bath  at  a  temperature  of  /io°  or  thereabouts, 
aud  which,  being  introduced  in  the  form  of  liquid  (without 
scalding  the  patient)  becomes  solidified  at  the  end  of  one  or 
two  minutes,  at  the  temperature  of  the  body. 

We  have  carried  out  this  method  for  i5  years  (that  is, 
lo  years  before  Beck  of  Chicago)  at  our  Oise  Hospital  at  Berck, 
with  our  assistant  P.  Pesme,  who  mentioned  our  results  in  his 
thesis  (in  1900). 

We  used  at  the  beginning,  a  bougie  of  stearin  and  naphtol 
camphor  in  the  proportion  of  three  parts  of  stearin  to  one 
of  naphtol  camphor.  The  stearin  bougie  was  previously  steri- 
lized by  boiling  for  20  minutes  over  an  open  fire.  Before 
each  injection,  we  used  to  dissolve  our  paste  in  the  water-bath. 


OUll    I'ASTK     lOR    INJECTION     IN     GASES    Ol'    EISTLL/E  1 7;> 

liiimcdialelv  it  li(|nilicd,,  we  iiijccled  it  and  kept  il  in  place 
with  a  lani[)on,  until  it  Avas  solidified;  that  occurred  after  one 
or  two  minutes. 

The  injections  were  repeated  every  3  or  /|  days,  until  5  or 
()  injections  had  been  given. 


Fig.  157.  —  Tlie  dressing  after  injec- 
tion. I.  Two  tampons  crossing 
each  other  over  tlie  fistula  to  pre- 
serve its  occlusion. 


Fig.  1 58,  —  2.  An  assistant  holds  the  tam- 
pons Avhilst  the  bandage  is  applied,  the 
pressure  of  -which  keeps  the  liquid  in 
place,  until  the  next  injection. 


We  have  obtained  cures  by  this  method;  but  we  observed 
sometimes  in  cases  of  fistulous  passages  leading  into  cavities 
larger  than  the  tracks,  phenomena  of  retention,  such  as  are 
noticed  as  well  with  injections  of  paraffin  pastes  :  this  is  due 
to  the  fact  that  stearic  acid  and  paraffin  have  a  melting  point 
relatively   high    (60'^    about),  and  are   substances    but   slightly 


I'jG  TLBERCLLOLS    FISTUL.E.     INJECTIONS 

absorbable.      That  is  Avhy  we  use  hardly  anything  else  to  day  but    . 
the  follo\Ying  preparations,  which  give  us  every  satisfaction'. 

Our  paste  jn"  i. 

Phenol  camphor )      ,,       . 

,T     1  ,  1             1  I      aa      6  srammes. 

jNaphtol   camphor ' 

Gaiacol i5  — 

Iodoform 20  — 

Lanoline  for  spermaceti) lOO  — 

The  melting  point  is  about  4o°  (slightly  above). 

Our  paste  y°  2. 

Phenol  camphor }      , .        „ 

--     ,     ,        ^   ,  i      aa       C)  grammes. 

iNaphtol  camphor J  ° 

Gaiacol 8        — 

Iodoform lO        — 

Lanoline  (or  spermaceti) loo        — 

The  melting  point  is  about  4o°  (slightly  above). 

The  first  of  these  pastes  being  twice  as  active  as  the  second, 
we  use  it  for  cavities  or  fistulous  tracks  of  small  capacity,  that 
is,  of  less  than  lo  cc.  in  a  child,  and  of  less  than  20  cc.  in 
an  adult.  Inversely,  we  use  the  paste  n°  2  for  large  cavities, 
that  is,  those  exceeding  the  dimensions  we  have  just  given. 

You  may  inject  10  cc.  of  the  first  in  a  child  of  ten  years, 
and  up  to  20  cc.  in  an  adult. 

Of  the  second  paste  you  inay  inject  double  the  quantity,  that 
is  20  cc.  in  an  infant  and  /jo  cc.  in  an  adult. 

As  a  matter  of  fact  we  hardly  ever  reach  those  figures,  but 
they  may  be  reached  w^ithout  inconvenience. 

If  you  take  care  not  to  exceed  them,  you  will  never 
observe  a  serious  accident  of  intoxication,  whilst  there  have 
been  cases  of  death  Avith  the  bismuth  pastes.     Neither  will  you 

I.  \ou  can  prepare  these  pastes  yourself,  as  we  have  personally  done,  or 
you  can  order  them  from  your  pharmacist,  if  you  are  certain  of  his  asepsis, 
or  you  may  inc£uire  of  Messieurs  Ducatte,  or  Johan,  or   Gogibusof  Berck. 


THE    METHOD    OT     USING    OLll    I'A.STi:    AS     INJECTIONS 


77 


have    anv     ac<i<l<'nls    llirough    rcleiitioii  '    aa  illi    our    prepara- 
tions. 

As  lo  llic  lei'liuique,  it  is  llic  same  as  llial  indicated  above 
for  iiijeclion  of  the  stearic  acid  and  naphtoi  camphor  paste, 
that  is,  \ou  soften  tlic  paste  in  a  \vatcr-l:)ath,  tlien  you  charge 
the  syringe,  previously  warmed  (in  hot  boiled  water),  and  imme- 
(lial('l\  introduce  the  injection  into  (lie  lislulous  track  in  the 
A\a\   reprcsenteil  in  fig.   log. 

A\e  Avill  go  into  some  of  the  details. 

The  flask  of  paste,  opened,  is  placed  in  water  in  a  saucepan 
heated  by  a  spirit  lamp  or  by  gas.  After  some  minutes,  the 
paste  softens;  then  stir  with  a  glass  rod  in  order  to  render  it 
homogeneous. 

Then,  from  the  wide-mouthed  flask  containing  the  paste, 
charge  your  syringe,  which  has  previously  been  warmed  by 
filling  and  emptying  two  or  three  times  with  hot  water  which 
has  been  boiled  (at  ^o'^  or  45°) ;  attach  to  the  syringe  a  metallic 
nozzle  appropriate  to  the  shape  of  the  track  and  already  warmed 
like  the  syringe,  in  hot  w-ater.  Immediately  push  the  injection 
into  the  fistula. 

If  several  fistula?  exist,  push  in  the  whole  of  the  injection 
by  one  only  of  the  orifices,  which  you  knoAV  to  be  in  commu- 
nication with  the  others ;  Avhilst  the  injection  is  jDenetrating, 
close  all  the  other  openings  Avith  tampons  supported  by  one, 
two,  or  three,  improvised  assistants. 

You  will  notice  that  there  is  a  double  danger  to  avoid. 
The  first  is  that  of  injecting  the  liquid  too  hot,  in  which  case 
you  run  the  risk  of  scalding  the  patient.  The  second  is,  on 
the  contrary,  injecting  the  liquid  too  cold,  in  which  case  the 
fluid  will  solidify  in  the  syringe  before  you  have  time  to  inject 
it.     You  will  easily  succeed,  with  a  little  practice,  if  you  guard 

I.  It  remains  to  he  well  understood  that  \ou  never  make  a  modifying 
injection  of  any  kind  in  case  of  injected  tuberculous  fistuhe,  as  is  explained 
on  p.  238. 

C.vLOT.  —  Indispensable  orthopedics.  12 


178 


TUBERCULOUS  FISTUL.^ 


against  this  double  clanger,  which  is,  olhenvise,  hut  little  to  he 
feared,  if  you  use  our  paste. 

When  the  paste  is  liquified,  it  is  at  the  temperature  of  from 
4o°  to  45°;  you  then  charge  your  syringe  at  once.  If,  at 
this  moment,  the  paste  appears  to  he  too  hot,  which  the  prac- 
titioner can  judge  hy  simply  feeling  the  syringe,  Avait  5,  10  or 
1 5  seconds  before  injecting  :  Avait  until  it  has  cooled  down  to 
about  4o°,  which  is  the  right  temperature,  neither  too  hot  nor 
too  cold,  for  injection. 

Push  your  injection  neither  too  roughly  nor  too  sloAvly; 
take  5  or  10  seconds,  for  example.  I  am  in  the  habit  of  using 
a  large  syringe  of  20  cc.  capacity,  hut  the  ordinary  small 
syringe  can  be  used. 

If  the  cavity  is  small,  the  piston  of  the  syringe  is  very 
soon  arrested,  or,  the  fluid  may  return.  In  that  case  you  keep 
the  syringe  in  its  place  until  the  solidification  of  the  liquid 
paste  is  effected. 

If  the  cavity  is  very  large,  if  it  is  not  filled  hy  the 
contents  of  the  syringe  (which  happens  sometimes  when  only 
a  small  syringe  is  at  your  service),  quickly  remove  it 
(keeping  up  pressure  over  the  orifice  with  a  tampon),  then 
charge  it  afresh  to  inject  a  second  dose,  and,  if  need  be,  a 
third,  until  you  reach  the  quantity  of  paste  given  above. 
Nearly  always  you  will  have  to  stop  before  this  on  account 
of  the  resistance  offered  to  the  penetration  of  the  liquid,  and 
sometimes  hy  the  painful  sensation  of  fullness  complained  of 
hy  the  patient.  However,  Avhen  there  is  but  little  pain, 
you  need  not  take  much  notice  of  it,  it  will  pass  off  almost 
immediately. 

Once  the  solidification  of  the  paste  is  produced,  apply  the 
dressing. 

The  subsequent  reaction  is  variable;  sometimes  there  is 
none,  in  other  cases  it  may  be  accompanied  by  a  fever  of  38° 
or  39"  for  or  one  tAVO  days  (I  speak  ahvays  of  non- infected  fis- 
tulee,   for  in   fistuke   Avhich  are  infected,    the   reaction  may  be 


riiCIIMOl  r.    ttl'    TlIC     INJECTION    OF    OL  U    PASTE 


179 


much  inoro  active,  and  in   llicm,  as  yon   know  .  injcclions  arc 
contra-iiuUcalcd  lor  otlicr  reasons). 

In  case  of  fever,  remove  the  dressing-  next  day  and,  if  the 
region  is  red  and  tense,  apply  a  damp  dressing;  if  it  is  not, 
apply  an  ordinary  dry  one.  At  any  rate,  when  there  is  no 
fever  following  the  injection  yon  must  change  the  dressing  on 


Fig.  i5g.  —  Technique  of  the  paste  injection  when  there  are  several  fistulse  present. 
There  were  eight  in  the  present  case.  You  introduce  the  nozzle  straight  or  cur- 
ved according  to  the  case;  into  the  most  accessible  passage;  Avhile  one,  two  or  three 
assistants  armed  with  tampons  block  the  other  orifices,  you  push  in  the  injection 
gently  and  evenly,  without  jerking.  You  hold  on,  with  the  help  of  the  assistants, 
until  the  paste  is  solidified  which  requires  about  a  minute  and  a  half  to  take 
place}. 

the  fourth  or  fifth  day,  and  even  sooner  in  cases  where  the 
discharge  is  very  abundant. 

Sometimes  the  discharge  dries  up  at  once.  I  have  observed 
the  fact  several  times.  I  have  seen  especially  a  discharge,  con- 
tinuing for  three  years,  dry  up  after  a  single  injection  of  paste 
of  naphtol  camphor.  That  was  the  case  in  the  patient  repre- 
sented on  p.  282  (fig.  igi). 

Scarcely  ever,  however,  is  the  result  so  complete  and  so 
rapid.     The   discharge   does    not    cease,    still    it    is    already  a 


l8o  TUBERCULOUS    FISTUL.E.    INJECTION    OF    OUR    PASTE 

little  modified;  it  contains  debris  of  the  paste;  it  is  more 
serous. 

Make  a  second  injection  on  the  fourth  or  fifth  day  after 
the  first  one.  Recommence  the  injections  of  j^aste  every  four 
days,  until  they  amount  to  seven  or  eight  injections. 

Then,  a  period  of  Avaiting  of  equal  duration  —  3o  days, 
after  vs^hich  the  fistula  is  often  closed ;  if  not,  recommence  a  new 
series  of  injections  and  a  new  period  of  rest,  and  so  on  for  six 
months.  Then,  three  or  four  months  of  rest  and  aseptic  dres- 
sings, without  injections  as  above,  until  you  have  obtained  a 
cure,  which  will  happen  nearly  always  S  even  in  fistulae  of 
osseous  origin,  provided  that  we  have  to  deal  Avith  non-infected 
fistulte  and  that  the  patient  is  placed  under  good  general 
treatment  (life  in  the  country,  or  better,  by  the  sea). 

Refer  to  p.  2  25  and  ouAvards  as  to  the  question  of  the  prog- 
nosis of  tuberculous  fistulre  ;  here,  as  we  have  already  said, 
we  are  speaking  of  the  proper  technique  of  the  injections  only. 

I.  We  have  used  bismuth  pastes  in  the  same  iva)  ;  but  they  have  given 
much  less  satisfactory  results  than  our  own  prejjarations  of  naphtol-camphor, 
gaiacol  and  iodoform. 


The  children  of  the   '■   InsUlut  oithopeJique  "  of  link,  on   llic  sands. 


SPECIAL  TECHNIQUE 

OR 

A  Study  of  each  External  Tuberculosis  and  of  each 
Deformity,  in  detail. 


FIRST   PART 

ACQUIRED  ORTHOPCEDIC  AFFECTIONS 
OF  TUBERCULOUS  ORIGIN 


CHAPTER   IV 

ON  THE  PROGNOSIS  AND  TREATMENT  OF 
EXTERNAL  TUBERCULOSES 

A.  —  The  attitude  practitioners  take  in  the  presence 
of  these  affections. 

How  many  times  have  I  wished  that  [)raclitioners  who 
have  the  treatment  of  hip  disease,  or  of  Pott's  disease,  or  of 
white  SAvelhngs,  would  come  and  pass  a  few  davs,  or  even  a 
few  hours,  at  Berck,  where  external  tuberculoses  come  to  us 
in  thousands  from  all  over  the  world  I  A  simple  visit  would 
spare  them  many  disappointments  and  disasters,  in  shoAving 
them,  so  to  speak,  the  watchword,  and  putting-  them  into  the 
proper  state  of  mind  for  carrying  out  the  treatment  well. 

They  would  carry  away  as  "  souvenirs  "  of  Berck,  the 
capital  notions  Avhich  follow  and  which  are  too  little  knoAvn, 
and  which  also  summarise  «  all  the  wisdom  »  acquired  con- 
cernin.ff  external  tuberculoses. 


Tin:    iiusr   viitriEio   hk   aciu  iukd.  —  i'ATIENCE  \H'S 

1.  Tli(>  duration,  particularly  long,  ol  lliesc  affections, 
is  thai  ol'  one  year  lor  a  inininium,  and  ol'lcn  several  years^ 
The  obligation  resting  upon  the  practitioner  to  Avatch  over 
his  patient,  not  only  during  the  long  period  of  activity  of 
the  disease,  but  far  beyond  that,  for  perhaps  one  year,  tAvo 
years,  three  years,  in  default  of  Avhich  a  relapse  may  occur, 
and  the  entire  orthopoidic  results  obtained  up  to  that  time, 
lost. 

2.  The  necessity  for  all  patients  to  live  out  of  doors  from 
morning  until  evening,  in  all  seasons  and  in  all  weathers", 
in  a  perpetual  bath  of  pure  air  and  sunlight. 

3.  The  necessity  for  keeping  at  rest  in  the  recumbent  posi- 
tion, of  patients  afflicted  Avith  Pott's  disease,  hip  disease  or 
tuberculosis  of  the  loAAer  limbs,  until  the  focus  is  extinguished, 
that  is,  in  many  cases,  for  several  years. 

^^  ell,  all  this  you  Avill  learn  in  a  short  visit  to  Berck.  At 
the  same  time  you  Avill  see  hoAv  the  tAvo  indications  for  outdoor 
life  and  the  recumbent  position,  Avhich  are  considered  by 
some  people  to  be  irreconcilable  ^  are  in  reality  easy  to  recon- 
cile, eAen  for  people  of  small  means.  The  only  thing  is  to  put 
the  patients  on  a  "  cadre  ". 

1 .  In  reality,  If,  in  their  common  forms,  these  tuberculoses  can  be  cured 
in  a  year,  it  is  only  on  the  condition  of  their  being  treated  by  injections  made 
into  the  focus.  Without  injections  it  will  be  necessary  to  reckon  three,  four 
or  five  years.  Unhappily,  there  are  cases  ^^■here  the  injections  are  not  practi- 
cable; for  example,  Pott's  disease  A^ithout  abscess;  the  vertebral  body,  the  seat 
of  the  lesion,  is  too  far  away  to  be  reached  by  the  syringe  without  uncertainty 
and  without  danger. 

2.  They  are  clothed  in  a  suitable  way,  and  sheltered  if  need  be. 

3.  That  Avhich  makes  them,  so  often,  sacrifice  the  one  to  the  other. 

The  Germans  and  the  English,  in  carrying  out  the  general  treatment 
before  the  local  treatment,  allow  their  patients  to  walk  alDout,  to  ensure  for 
them,  above  all  things,  life  in  the  open  air. 

The  French,  on  the  contrary,  give  the  preference  to  the  local  over  the 
general  treatment,  keeping  their  patients  in  bed  «  in  the  Avard  »  (as  one  sees 
in  many  hospitals  for  children)  —  Avhich  is,  perhaps,  a  worse  mistake. 

The  correct  formula  is.  — plenty  of  air  and  perfect  rest  at  the  same 
time. 


nil    I'viiiMs   \i\i)i:    lo  i.i\i;   IN  Tin:  open  aiu  i85 

lloie  is  a  verv  simple  model  ol"  a  wooden  bed  (cadre)  with 


""^7 


Fis.   162-  —  T lie  bed  upon  \Yliicli  the  patients  lie. 

a  mattress  of  horse-hair,  designed  so  that  it  may  be  construc- 
ted everywhere. 

The   patients  are   laid   horizontally  and   strapped  on  these 


l^ 


Fig.  I  Go.  —  The  bed  is  placed  on  this  wooden  frame. 

beds,  provided  with  a  handle   at    each   end    to  allow  cf  their 
easy  removal  into  the  open  air. 


1 86       THE    NECESSITY    FOR    REST    IN    THE    RECUMBENT    POSITION 


The  patients  are  thus  carried  every  morning  out  of  doors ; 
they  pass  the  day,  immohiles,  either  on  trestles  or  on  a  chassis 
(about  a  metre  high),  or  even  simply  on  the  ground,  or  taken 
out  in  the  small  carriages  (such  as  those  you  see  by  hundreds 
furroAving  the  sands  at  Berck ' . 

4.  lou  learn  also  at  Berck  that,  contrary  to  Avide-spread 
prejudice,  the  patients  do  not  pine  away,  nor  are  wearied, 
in  the  recumbent  position. 


Fio-.  iG'i 


In  default  of  trestles,  the  bed  is  placed  on  two  chairs. 


The  first  thing  Avhich  strikes  and  surprises  all  the  visitors 
is  the  very  happy  countenances,  rosy  and  plump,  of  all  the 
patients,  extended  on  their  beds.  Therefore,  medical  men  will 
be  able  to  reassure  parents  Avho  are  fearful,  a  priori,  for  the 
general  health  of  their  children,  and,  as  to  the  effects  of  the 
recumbent  position  kept  up  for  so  long  a  time. 

HoAv  natural  and  essential  this  position,  Avhich  seems  so 
abnormal  elsewhere,  appears  at  Berck  ! 

At  Berck  —  owing  to  the  surroundings,  and  to  the  example 


1 .  The  same  is  clone  for  all  afTections  (other  than  the  external  tubercu- 
loses) the  treatment  of  which  recjriires  a  long  rest  (namely  rickets,  infantile 
paralysis,  congenital  dislocation  of  the  hip,  osteomyelitis,  syphilis  of  the  bones 
and  joints,  etc.). 


TIM".   ni.i:i  Miii.M'    I'osi  I 


ION    AI.W  \\s     W  I.I.I.    TOI.KUA'n.l)  1 87 


i;ii;i:!iiiii'niii'iii;iiiii!L7^i;i:'inm'ia.itj'i;^ 


Fig.  i65.  —  Thanks  to  a  movable  reading  desk,  the  patient  is  able  to  read  and  work. 
As  can  be  seen,  this  patient  is  wearing  a  large  plaster  apparatus  for  Potfs  disease. 


Fig.   1 60.  —  The  patients  take  their  meals  in  the  open  air. 


1 88       AN   EASY    MEANS    OF    RECONCILING    THE    TWO    INDICATIONS 

set  to  the  new  patients  by  those  ah-eady  cured  —  everyone, 
from  the  day  of  arrival,  cheerfully  accomodates  himself  to  the 
common  regime  of  rest  in  the  recumbent  position. 

5.  Finally,  practitioners  Avould  learn  at  Berck  that  difficult 
and  nevertheless  so  important  thing  —  not  to  operate  on 
these  patients.  They  would  learn  that  the  knife  is  the 
enemy  of  these  affections '  ;  that  ihe  first  condition  to  cure 


Yi<y.  16-.  —  In  order  lliat  tliey  may  get  about,  the  ted  is  transferred 
to  a  small  carrlase. 


what  are  called  the  surgical  tuberculoses  is,  in  reality,  never 
(or  very  nearly  never)  to  perform  a  surgical  operation  and  to 
put  away  all  the  grand  array  of  instruments  in  order  to  take 
up  this  "  inglorious  "  work,  which  consists  in  making  injec- 
tions and  punctures,  gentle  redressments,  plastered  apparatus, 
dressings. 

I.  A  general  practitioner  may  agree  to  tliis  perhaps,  but  it  Avillbe  more 
difficult  to  convince  a  surgeon  who  has  generally  been  trained  to  place  all 
his  faith  in  the  knife. 


I.lir.    IN    THE    OPEN    Alll    AMI     IN    THE    UECUMBEM"   POSH  ION        18(1 

Why  these   affections   are  so  well  cured  at   Berck. 

In  iho  local   treatment    and   in   llic   observance  oi'  hvfrieiiic 
rules  and  general  treatment  lies  the  secret  of  the  cure  of  exter- 


Fig.  1 08.   —  A  patient   driving  his  own  carriage.     In  the  back!?round, 
other  carriaires  standins:. 


Fig.  i6c)    —  Patients  (at  Berck    meetlno-  for  conversation  and  enjovment. 


IQO 


SO    SURGICAL  OPERATIONS,  NO  VIOLENT  REDRESSMENTS 


"Fis;.  170.  —  AMien  the  disease  permits  of  some  movement  (as  in  the  case  of  this  child 
Avith  tuberculous  disease  of  the  foot),  the  bed  is  placed  on  the  sand  and  the  child 
joins  in  the  amusements  of  his  friends  -who  are  already  cured. 


IFig.  171.  — These  two  children,  suffering  -with  Pott's  disease,  have  been  recumbent 
and  plastered  for  18  months.  One  can  see  that  their  general  condition  leaves 
nothino  to  be  desired. 


IIIE    SKCRET    Ol'    THE    CURES    AT    13ERCK  1  ()  I 

iial    lubcivuloscs   at    Bcrciv  —  not    rorficlling,    mind    you,   to 
allow    I'or  the  effect  of  the  sea-air. 

It  is,  llianivs  lo  lliat.  that  the  medical  treatment  is  reduced, 
at  Borck,  to  almost  nothing-.  The  keen  air  of  the  sea  shore 
stimulates  the  appetites  of  the  patients  and  ensures  the  good 
operation  of  the  digestive  organs.  They  eat  "  double  ",  they 
digest  well,  ihey  groAV  fat  —  and  therefore  have  never  —  or 
hardly  ever  —  need  for  medicaments. 

One  may  recapitulate,  in  a  few  words,  what  is  necessary 
to  be  done  to  cure  the  large  external  tuberculoses  ; 

•  Prolonged  Rest  —  Life  in  the  open  air  —  Rational 
overfeeding  —  Modifying  injections  —  Well-made  appa- 
ratus. 

AMth  this  additional  advice  on  what  is  not  to  be  done  :  — 
((No  surgical   interference  —  No  violent  redressment.  " 


192     Oy    THE  PROGNOSIS  OF  THE  EXTERNAL  TUBERCULOSES 

B.  —  Prognosis  of  These  Affections. 

The  risks  of  death  and  the  means  of  preventing  them. 

As  soon  as  you  have  made  the  diagnosis  of  Pott's  disease, 
hip  disease  or  white  SAvelling,  you  will  ask  yourself  —  before 
even  speaking  of  treatment  —  will  the  patient  be  cured  ? 

In  order  that  you  may  answer  the  cjuestion,  we  will  pro- 
ceed to  describe  what  are,  in  the  above  diseases,  the  risks  of 
death  and  what  are  the  means  taken  to  guard  against  them. 

The  risks  may  be  arranged  under  three  chief  heads  : 

1.  Slow  septic femia  leading  to  visceral  degeneration. 

2.  Generalised  tuberculosis  (in  the  lungs,  kidneys  or  blad- 
der). 

3.  Meningitis,  which  is,  correctly  speaking,  only  one  form 
of  generalised  tuberculosis,  but  requires  special  mention  on 
account  of  its  importance. 

I.  Slow  septicsemia,  hectic  fever  and  visceral  degeneration. 

■fig.  172,  173  and  17U). 

This  is  the  cause  of  nine-tenths  of  the  deaths  in  Pott's 
disease  and  hip  disease  —  it  is  the  same  at  Berck  as  in  Paris. 
Twenty  years  ago,  at  the  "  Hopital  Maritime  ",  a  series  of 
twelve  cases  of  Pott's  disease  which  had  suppurated,  Avere  ope- 
rated upon  and  curetted  by  the  great  surgeon  Cazin  of  Berck. 
Eleven  of  them  succumbed  before  the  end  of  the  first  year,  and 
the  tAvelfth  the  year  afterwards,  all  carried  off  by  slow  pro- 
gressive wasting  of  the  body  (hectic  fever  and  albuminuria) 
Avhich  followed  the  operation  at  3,  6,  9  and  10  months.  Of 
100  cases  of  hip  disease  resected  about  the  same  time  by  the 
same  expert  surgeon,  90  Avere  dead  in  less  than  ten  years 
after  the  operation,  carried  off,  also,  by  sIoav  septic£emia  and 
hepatic  and  renal  degeneration. 

This  terrible   denouement  Avas  so  classical  that  one  used  to 


xiiuEE  u\>ui;hs  or  di-atii 


193 


say  at  once  of  every  cliild  stricken  witli  hip  disease  or  sii|)i)ii- 
rated  Pott's  disease.  "   He  is  a  dead  cliiid. 

But  I  speak  of  twenty  years  ago ! 

Today    this   IViiililful   niirlitinare   is  al  an   end!   Evervlliin"- 


rig.   172.  —  Pott's  disease  with  fistulae ;    the  cacheiia  is  made  apparent   in  this  child 
by  an  exceedingly  large  liver.    Fig.  178  ,  albuminuria  and  fever  (v.  fig.   i~\,- 

is  changed,  so  thoroughly  changed,  that  the  reverse  is  now 
true.  The  late  in  store  for  these  patients  is  not  death,  but  cure. 
\N  e  like  to  repeat,  in  the  familiar  causeries  of  our  practice, 
that  our  profession  (especially  with  regard  to  us  who  study 
external  tuberculoses)  was  at  one  time  the  worst  of  all.  the  most 

Calot.  —  Indispensable  orthopedics.  i3 


194 


I.     SLOW    SEPTICEMIA   WITH   VISCERAL    DEGENERATION 


depressing,  the  most  demoralising  ;  that  to  day  it  is  the  most 
beautiful,  the  most  comforting,  that  which  produces  the  most 
numerous  and  excellent  cures,  that  in  which  we  have  the 
greatest  certainty  of  being  useful. 

What  has   Avorked  this  miracle?     It  should  be,  here  as  in 


Fig.   173.  —  jNormal  outline  of  the  liver. 


all  other  departments  of  surgery,  the  advent  of  antiseptics  and 
the  perfection  of  technique.     Never! 

It  is  not  because  we  perform  the  operations  more  asepti- 
cally,  more  correctly  and  more  rapidly ;  it  is  simply  because 
we  operate  upon  them  no  longer. 

For,  by  not  operating  upon  the  tuberculoses,  by  not  ope- 
ning the  bacillary  foci  (nor  allowing  them  to  open),  we  close 
the    door   to    external  septic  infections,   whilst,    by   operating 


TO    AVOID   THIS.    NEVER   OPEN    TUIiERCULOLS    lOCl 


I  (JO 


upon  lluMu  (however  clever  the  operator) '  a  door  is  opened 
for  llie  sccondaiN  scplir  inleclidns  A\liicli  conduct  the  palicnl  lo 
dealli'-.  That  is  wlial  we  have  learned  in  an  experience  of 
twenty  years. 

All  that,  we  have  already  said  ;  il'  we  return  to  it  once 
more,  it  is  because  it  is  necessary,  seeing  that  so  many  sur- 
f^eons   or   |)h\slcians    persist   in   closing    their   eyes  to    the 


I^i 


;fsv 


frf 


'±l:±Y^ 


f 


-H 


■t- 


i-± 


'^jy' 


"-i.. 


f- 


A  — 


Fig.  ly/i.  —  Portion  of  cliart  in  the  case  of  the  child  in  fig.  172  sulTering  with  Pott's 
disease  and  operated  upon  (incision  and  scraping)  for  an  abscess  in  the  right  iliac 
fossa.  The  patient  succumbed  in  the  thirteenth  month  of  hectic  fever  and  degene- 
ration. 

light  and  still  transgress,  every  day,  the  great  command- 
ment, the  fundamental  dogma,  of  never  opening  tuber- 
culous foci. 


The  Means  of  Preventing  the  first  Risk  of  Death. 

These  means  you  have  guessed  at ;  they  are  most  simple, 
and  observe  that,  in  reality,  it  gives  us  less  trouble  nowadays 
to  cure  our  patients  than  it  did  formerly  to  kill  them. 

1.  Tlie  great  surgeons,  aaIio,  bv  tlieir  so-called  radical  operations,  under- 
take to  remove  the  whole  of  the  trouble,  will  succeed  only  in  one  thing;  they 
A^iil  remove  everything the  patient. 

2.  «  In  closed  tuberculoses,  cure  is  certain.  To  open  the  tuberculoses 
(or  allow  them  to  open)  is  to  open  a  door  by  Avhich  death  too  often  wil 
enter.  » 


igG  SECOND   RISK    :     THE    GENERALISATION   OF   TUBERCULOSIS 

What  must  be  done?  In  the  presence  of  a  non-suppura- 
ted tuberculosis,  abstain  from  any  cutting  operation  ;  in  the 
presence  of  a  suppurated  tuberculosis  do  not  touch  it  if  the 
tuberculous  foci  are  difficult  to  attack,  in  ^Yhich  case  they  do 
not  threaten  the  skin ;  when  they  do  threaten  it  and  they  are 
then  easily  accessible,  puncture  and  inject  them;  Ave  have 
described  hoAV  to  do  this  (v.  Chap.  III). 

Then  you  Avill  cure  hip  disease  and  Pott's  disease,  always, 
or  nearly  always. 

And  not  only  you,  but  also  the  second  year's  student,  who 
knows  how  to  make  a  puncture  and  an  injection,  will  cure 
external  tuberculoses  infmitely  better  than  the  great  surgeon 
Avho  is  anxious  to  operate  upon  them  at  all  costs.  As  you 
see,  you  require  only  the  inclination  to  be  able  to  suppress 
this  first  and  great  risk  of  death  which  threatens  patients 
suffering  from  the  grave  external  tuberculoses  :  slow  septicsemia 
and  visceral  degeneration. 

2.     The  Danger  of  a  Generalisation  of  Tuberculosis. 

This  risk  is  much  less  than  the  preceding  one  —  it  is 
nearly  as  little  as  the  first  is  great.  Nevertheless,  attend  care- 
fully to  Avliat  I  say. 

If  at  Berck  we  scarcely  ever  see  this  generalisation  —  only 
perhaps  once  in  a  hundred  cases  —  it  is  because  Berck  is, 
Avithout  contradiction,  the  ideal  locality  for  these  maladies, 
and  is  especially  suitable  for  childrean.  It  is  certain  that 
for  subjects  —  especially  adult  subjects  —  living  in  bad  sur- 
roundings, the  risk  of  generalisation  Avill  be  A^ery  real.  It  is 
not  A^ery  rare  to   find  it   in   the  large    tOAvns,    Avhere  patients 


I.  I  say  nearly  always  because,  in  spite  of  all  the  efforts  made  to  hinder 
the  opening,  one  will  not  be  absolutely  successful  in  every  case ;  for,  if  the 
technique  of  punctures  and  injections  is  relatively  easy,  it  is  nevertheless  very 
minute,  and  one  may  make  mistakes  in  applying  it  —  "  errare  humanum 

est  ". 


IS    HARDLY    KVEU    SEEN    AT    Itl^HCK  K)- 

M'lio  have  commenced  with  a  Poll's  disease,  or  hip  disease,  or  a 
white  s\Ycning  of  the  knee,  finish  ^Yilh  Inhcrciilosis  of  (he  lunp-. 

How  can  the  danger  be  warded  oil? 

The  rcmcdv  should  be  to  make  all  these  patients  live  by 
the  sea;  but  it  is  impossible,  evidently,  for  most  of  them  to 
do  so,  and  this  is  why  practitioners,  wherever  they  are,  ought 
to  know  how  to  treat  the  external  tuberculoses.  (They  Avill, 
I  hope,  give  me  credit  that  I  am  endeavouring  to  assist  them, 
and  that  this  book  has  no  other  purpose). 

However,  I  Avill  say  to  them,  your  patient  cannot  go  to 
the  sea-side;  therefore  he  is,  certainly,  a  little  less  well  armed 
against  a  generalisation  of  tuberculosis,  maybe ;  but,  at  least, 
you  do  not  accentuate  this  drawback,  nor  lessen  —  by  the  kind 
of  life  you  allow  him  to  lead  —  the  very  great  chances  of  cure 
which  remain  to  him. 

I  will  explain  what  I  say. 

AA  hat  makes  the  superiority  of  a  sojourn  at  Berck  is  not 
only  that  the  pure  air  is  more  tonic  than  at  other  places,  but 
that  the  patients  profit  more  by  it. 

For  our  patients  at  Berck  —  hip  cases,  Pott's,  etc.  —  live 
in  the  open  air  from  morning  till  evening  in  all  seasons  and  in 
all  weathers,  keeping  always  at  rest,  reclining  on  "  cadres  ", 
on  the  small  carriages  that  promenade  the  sea-shore  (fig.  170). 
I  intentionally  insist  on  this  point. 

But  what  do  you  see  in  the  country,  and  especially  in  a 
large  town.>^ 

You  see  patients  affected  with  hip  disease.  Pott's  disease, 
white  swelling,  who,  especially  if  they  are  at  all  suffering,  are 
shut  up,  hidden  away  in  their  chambers  and  in  bed  with 
every  chink  stopped  up.  This  they  do  for  material  reasons; 
because  one  has  not  contrived,  and  one  does  not  know  how  to 
contrive,  their  going  out  of  doors  ''  in  bed  ";  they  have  not, 
as  a  rule,  either  a  transportable  bed  nor  a  carriage. 

And  also,  for  moral  reasons;  because  the  patient  himself 
refuses  to  go  out,  and  because  his  parents  avoid  making  him 


I  go        GENERAL  [SATIO>'   OBSERVED   I>"   THE    UMIEALTT    MIDDLE-CLASS 

do  SO  ;  he  does  not  aa  ish  to  be  seen,  and   they  do  not  Avish  to 
expose  him. 

A  young-  lady  afflicted  AA"ith  Pott's  disease,  and  lying  on 
her  mattress  in  a  carriase.  said  to  me.  "  Imagine  mv  feelings 
if  I  AAere  carried  about  the  streets  of  our  little  toAAii  in  this 
turn-out!      At   CA^ery  step,    I  shoidd  be  obliged  to    submit   to 


Fig.  i'j5.  —  At  Berck,  our  palienl?  pass  the  ^vhole  clay  on  the  shore;  their  carriages 
are  fitted  with  a  leather  apron  and  a  hood,  which  protect  them  from  the  glare  of 
the  sun  and  from  the  rain. 


the  remarks  and  condolences  of  strangers,  and  still  Avorse  of  my 
friends,  and  I,  in  this  long  Ioaa"  carriage,  going  at  a  foot  pace, 
should  think  I  AAere  on  a  bier;  anyAAhere  else,  I  should  be  a 
phenomenon,  Avhilst  at  Berck...      I  am  in  the  fashion  I 

And  this  is  AA'hy,  in  the  country  and  in  toAAUs,  the  patients 
"  moulder  "  in  their  chambers,  Avhich  they  ncAcr  leaAC.  Or, 
they  AA'ho  ought  to  be  resting  on  a  bed  completely  horizontal, 
so  as  to  fulfil  the  best  conditions  for  the  repair  of  their  hip  disease 
or  Pott's  disease,  are  unAA'illing  to  go  out,  except  upright,  AAith 
or  Avithout  an  apparatus. 


i.N   (JUDEU    i(»   i'iu:\r:\i'   it,    r.ivi;   i\   iiie  ori:\   aii;  i()() 


The  Remedy  for  this   Risk  of  Generalised  Tuberculosis. 

As  to  the  remedy,  there  is  only  one.  for  your  pMiicnls  who 
are  reslricled  lo  the  country  or  to  lowii  lile. 


Fig.  176.  —  This  is  what  you  could  do  everywhere  in  the  country.  AMiite  swelling  of 
the  knee.  The  patient  immobilised  on  a  bed  (the  bed  of  wood,  the  mattress  of 
liorse-hair)  which  is  carried  into  the  court  or  into  the  garden,  where  he  passes  the 
day.  Those  suffering  from  hip  disease  and  Pott's  disease  are  laid  entirely  flat, 
without  a  pillow. 

\ou  must  take  your  courage  In  both  hands  and  impart  it  to 
your  patients,  to  triumph  together  over  all  the  prejudice  and 
all  the  obstacles  Avhich  would  prevent  them  living  out  of  doors. 

In  the  country  this  is  relatively  easy  to  accomplish.  The 
patient  cannot  have  a  carriage,  it  would  cost  too  much,  mate- 
rially and  morally;  very  well,  be  it  so,  he  need  only  be  strapped 
on  a  large  "  cadre  "  and  carried  in  the  morning  into  the  garden, 
Avhere  he  will  pass  the  entire  day  (fig.  176). 

In  a  town,  it  is  less  easily  managed,  I  admit,  for  those  pa- 
tients who  are  not  able  to  go  away,  and  who  possess  no  garden 


200  ONE    ATOIDS   IT    ALSO    BT    GOOD    LOCAL    TREATMENT 

of  their  o^AIl;  but  they  might  be  able  often,  Avith  a  little  courage 
and  initiative,  to  be  carried  into  the  neighbouring  square  and 
remain  there  for  many  hours,  A^  hen  once  the  habit  has  been 
acquired,  nothing  could  appear  more  simple. 

If  you  do  this,  if  you  have  the  necessary  energy  and  courage 
to  carry  out  your  intention,  informing  your  patient  and  his 
friends  that  a  cure  is  the  prize  to  be  Avon,  you  Avould  overcome 
almost  certainly  the  risk  of  generalised  tuberculosis  Avhich  is 
the  second  risk  of  death. 

But  it  is  not  only  by  good  general  treatment  that  you  can 
accomplish  this. 

It  is  certain  that  a  defective  local  treatment  may  lead 
to  a  risk  of  generalisation;  for  example,  a  cutting  operation  is 
not  only  objectionable  because  it  opens  the  door  to  septic  infec- 
tions and  visceral  degenerations,  but  also  because  it  creates  a 
risk  of  inoculation  of  the  lungs  and  other  organs. 

Erasion,  the  scraping  doAvn  of  tuberculous  tissues,  Avhich 
causes  hoemorrhage  in  all  such  interferences,  setting  at  liberty 
tuberculous  bacilli  AAhich  may  moAe  off  to  colonise  far  aAA-ay, 
explains  too  Avell  certain  post-operative  tuberculous  generalisa- 
tions. I  have  obserAed  it  undoubtedly  incases  in  my  OAvn  prac- 
tice fifteen  or  tAventy  years  ago,  at  the  time  Avhen  I  still  operated 
upon  external  tuberculoses. 

Add  to  all  this  that  operations,  in  lessening  the  general 
resistance  of  the  patient,  render  the  organism  still  more  vulne- 
rable and  more  "  inoculable  ". 

The  non-immobilisation  of  painful  osteo-arthrites,  the  vio- 
lent redressment  of  deformities  of  the  hip.  of  the  back,  of  the  knee, 
may  also  favour  or  provoke  the  generalisation  of  tuberculosis. 

I  say  that,  in  order  to  do  aAvay  AA"ith  these  different  risks,  you 
must  ensure  perfect  repose  of  the  patient,  construct  comfortable, 
that  it  to  say,  Avell-fitting  apparatus,  neither  loose  nor  tight, 
aA'oid  rough  redressments,  and  replace  them  by  redressments 
Avhich  are  gentle  and  progressive. 


3""  meningitis;  mdiu-  haki:  at  the  sea-side  than  elsevvheue   aoi 

3.  There  Remains  the  Danger  of  Meningitis. 

All  llial  I  lia\c  jiisl  said  iiia\  he  a|)|trM'd  to  nicniiigilis.  I 
consider  lliat  in  improving  on  llic  one  pari  llic  resistance  oC  the 
subject  and  on  the  other  by  avoiding  anything  harmful  in  the 
way  of  local  treatment,  that  is  to  say,  any  culling  operation, 
any  roughness  in  redressmenl,  any  painful  treatment,  by  forbid- 
ding brain  work  and  exercise  or  premature  walking,  one  puts 
the  patients  under  the  best  conditions  for  preventing  the  onset  of 
meningitis. 

This  gives  me  an  opportunity  of  saying  something  as  to  the 
risk  of  meningitis  created  in  children  by  sojourning  by  the  sea, 
in  particular  by  sojourning  at  the  shores  of  the  INorth  of  France. 
I  believed  in  it  twenty  years  ago,  on  the  strength  of  the  classical 
treatises.  AA'ell,  I  do  not  believe  in  it  any  longer,  after  twenty 
years  experience  and  personal  observation. 

I  will  go  further  than  that  —  I  consider  to-day  that  it  is  the 
contrary  Avhich  is  true. 

But  first,  it  is  well  knoAvn  that  all  children,  and  with  stronger 
reason,  all  carriers  of  external  tuberculosis,  may  have  meningitis. 
And  it  is  still  more  true  of  those  avIio  are  debilitated  and  ill- 
conditioned. 

But  at  Berck,  children  are  better  than  anywhere  else  —  they 
eat  better,  breathe  better,  grow  fatter,  become  stronger,  and 
one  can  understand  that  they  must  be,  on  this  account,  more 
resistant  and  more  immune  against  meningitis  than  they  Avould 
be  anywhere  else. 

And  this  is  not  a  mere  fancy  nor  a  matter  of  opinion  —  the 
facts  are  there. 

I  have  scarcely  ever  seen  meningitis  —  only  one,  two  or 
three  cases  a  year  —  less  than  one  in  a  thousand  of  the  chil- 
dren afflicted  with  external  tuberculosis  Avhom  I  have  treated. 

But  I  hasten  to  add  that  that  has  been  so  for  only  a  dozen 
years !  I  observed  a  considerable  number  of  cases  of  meningitis 
in  former  years,  perhaps  ten  or  fifteen  yearly. 


202     TO    PREVENT    IT    :    ^'O    OPERATIO>%    >"0   YI0LE:VT    REDRESSMENT 

Do  you  know  why?  Because  at  that  time,  noAv  far  off,  I 
operated  upon  the  tuberculoses,  or  I  corrected  at  a  single 
sitting  tuberculous  deformities  (hip  disease.  Pott's  disease, 
white  swellings)  as  others  did  everywhere,  and  as  many  still 
do  to-day. 

AMien,  then,  certain  surgeons  put  forward  that  their  cases' 
of  forcible  redressment  of  hip  disease  did  not  shew  a  greater 
tendency  to  meningitis  than  those  left  untouched,  I  affirmed 
distinctly  to  the  contrary,  basing  my  opinion  on  the  results  of 
my  personal  experience. 

And  upon  another  surgeon  practising  at  a  maritime 
station  (notBerck)  stating  that  he  believed  that  he  had  observed 
an  appreciable  number  of  cases  of  meningitis  at  the  commence- 
ment of  their  sojourn  at  the  sea-side,  (that  is  to  say,  at  the 
moment  when  they  would  especially  feel  the  effect  of  sea-air, 
the  effect  being  too  stimulating  for  some  children),  I  replied 
that  I  had  never  seen  anything  to  confirm  that  opinion;  and 
that,  if  new  patients  are  more  disposed  to  meningitis,  it  is 
due,  in  my  opinion,  not  to  the  stimulating  effect  of  sea-air, 
but,  very  often,  in  some  marine  hospitals,  to  their  being 
operated  upon  or  forcibly  redressed  soon  after  their 
arrival  at  the  sea-side.  But  we  have  already  described 
the  grievous  influence  on  the  meninges  of  such  mischievous 
traumatisms.' 

I  could  cite  instances  in  support  of  what  I  here  advance. 
Without  wishing  to  spend  too  much  time  upon  the  question,  I 
have  said  enough  to  draw  the  following  conclusions,  which  I  ask 
you  to  remember. 

Practical  Conclusions. 

There  are  three  risks  of  death  in  the  external  tuberculoses  ;  — 
I.  Amyloid  degeneration  of  the  liver  and  of  the  kidneys,  which 
causes  nine-tenths  of  the  deaths. 

This  degeneration  is  due  to  the  opening-up  of  tuberculous  foci. 

In  order  to  guard  against  it,  it  is  sufficient  to  prevent  such 
opening-up.     In  other  words,  you  ought  never  to  operate  upon 


THEN    iiii:   TiiurE  iusks    vnr  \r\ni.^    \i.\\  ays  piu.vi'.m  iiti.i;      a<j3 

llic  liiherculoses,  never  In  ii|i(ii  ,111  ali-^rrss  1)n  f^i-;i\il.itiiiii.  hiil 
lo  [)imcture  and  injecl  il. 

■>.  ,1  (/cneralisnlion  of  litlicrctihisis  lo  llic  lumj,  la  llic  hidney, 
and  lo  Ihc  li/(i>l(l,T. 

\i)\i  will  ;i\nl(l  llii-^  iiOiirl\  ;il\\;i\s  if  llie  palicril  live  out  or 
doors  in  llic  dpcii  air  ['ir>]\\  im lining  lill  evening,  and  11"  you 
yourself  .ihsl.iin  IVoni  all  vidlcnl  interference  in  the  general 
treatment,  tliat  is  to  say,  llial  you  perform  your  redress- 
ments  of  hip  disease  and  Avliile  swellings,  gently  and  by  stages. 

3.  A  Meningitis. 

You  would  always  avoid  this,  or  nearly  ahvays,  by  increa- 
sing the  general  resistance  of  the  patient  (and  for  this  object, 
the  sojourn  by  the  sea  is  evidently  the  best;  which  does  not, 
of  course,  dispense  a\  Ith  walch  being  kept  during  the  stay, 
especially  if  it  is  a  question  of  a  nervous  child),  by  assuring  the 
cerebral  repose  of  the  patients,  by  your  abstaining  from  all 
cutting  operations  and  forcible  redressments  ' . 

It  is  possible  to  promise  a  cure. 

And  now  you  know  the  answer  you  have  a  right  to  give 
to  those  parents  who,  having  brought  you  a  patient  with 
external  tuberculosis,  ask  you  at  once  if  he  will  be  cured. 

Yes,  you  may  promise  them  that  he  will  be  cured,  or 
rather  that  you  w  ill  cure  him ;  for  he  wdll  not  be  cured 
unattended;  he  will  not  be  cured  if  he  is  treated  roughly;  he 
Avill  be  cured  because  you  know  what  is  necessary  to  be  done 
and  how  to  avoid  what  would  prevent  or  compromise  the  cure. 

1.  Wliich  does  not  mean,  I  repeat  it,  that  you  Avill  not  do  Avliat  is  neces- 
sary and  sufficient  for  the  redressment  of  vicious  positions.  No,  you  «ould 
correct  them,  but  in  the  right  manner.  Formerly,  I  used  to  make  forcible 
corrections  after  the  metliod  of  Bonnet,  of  Lyons,  Avhich  is  stitl  that  of  nearly 
alt  surgeons  (by  movements  alternately  of  llexion  and  extension,  movements 
carried  on  for  a  quarter  of  an  hour).  I  have  not  made  such  corrections  for 
many  years  now  but  I  succeed  as  Avell  today,  Avith  mild  measures,  slow  and 
progressive,  in  correcting  the  vicious  positions  and  keeping  them  corrected. 
And  you  will  succeed  erpially  well  if  you  follow  the  indication-;  given  in  this 
book  for  each  deformilv. 


204    PRI>CIPLES  OF  LOCAL  TREATMENT.  1st,  SUPPURATED  TUBERCULOSES 


C,  On  the  local  treatment  of  external  tuberculoses. 

The  following  considerations  are  directed  not  only  to  the 
tuberculoses  called  "  orthopoedic  "  (Pott's  disease,  hip  disease, 
white  sw^elling),  hut  also  to  tuherculoses  of  the  soft  tissues  (ade- 
nitis, synovitis,  epididymitis,  etc.). 

The  respective  value  of  the  different  treatments. 

I'*  In  the  suppurated  tuberculoses. 

In  the  presence  of  a  suppurated  tuberculosis,  what  would 
you  do.^ 

There  are  three  possible  treatments  : 

I***  Operation; 

a""*  Abstention ; 

3"'  Punctures  and  injections  ^ 

i"'  The  value  of  surgical  |operation  :  Without  doubt, 
surgical  operation  can  claim  a  large  number  of  cures,  when  it 
is  made  very  completely,  that  is  to  say,  in  disease  of  the  cer- 
vical [glands,  or  in  very   accessible  tuberculosis   in  the   limbs. 

Nevertheless,  you  know  very  well  that  to  go  very  widely 
beyond  the  limits  of  disease  is  not  an  absolute  guarantee  of  its 
cure ;  for  a  tuberculous  inoculation  of  tissues,  up  to  this  time 
sound  but  vascular,  and  brought  into  contact  with  bacilli  by 
the  operative  act  iteslf,  always  remains  possible  ;  this  accounts 
for  the  fact  that,  even  in  superficial  accessible  tuberculoses,  the 
largest  operations  often  leave  fistulee  behind. 

And  fistula  is  the  rule  (for  the  same  reason  and  especially, 

I.  I  have  not  mentioned  a  fourth  treatment,  the  method  of  de  Bier,  which, 
good  as  I  believe  it  to  be,  in  acute  phlegmonous  inflammation,  whitlows,  etc., 
is  of  no  value,  I  am  sure,  against  external  tuberculoses. 


THE    SIIOKT-GO.MINGS    OF    SUUGICAL    OPERATIONS  2o5 

because  opcralion  li;is  not  been  able  to  gut  beyond  ibc  liinils 
of  tbc  disease),  wbcii  deep  tuberculoses  of  bones  or  of  joints 
of  limbs  are  in  question,  and  especially  Pott's  disease,  forwbicb 
it  is  always  inipossii)le  In  pci-forni  a  really  complete  o[)cralir.ii. 

Fistula  is  the  rule...  Have  practitioners  tlie  least  doubt  as  to 
ibe  miscbief  tbey  bavc  done  in  transforming  tliis  Poll's  disease 
or  tliat  coxitis  unopened,  into  a  coxitis  or  a  Pott's  opened:' 

Closed,  Pott's  disease  lias  99  cbances  in  a  liundred  of  being 
cured ;  opened,  tbe  proportion  is  reversed  :  it  is  99  chances 
in  a  hundred  that  the  case  Avill  terminate  in  death  —  a  little 
sooner,  a  little  later.  That  is  what  the  practitioner  has  done, 
with  a  light  heart,  in  opening  an  abscess  by  gravitation. 

It  is  a  door  leading  to  death  Avhich  he  has  opened. 
Through  the  fistulae,  in  fact,  will  penetrate  septic  germs  cau- 
sing secondary  or  mixed  infections,  infections  associated  with 
the  pure  tuberculosis  which  has  existed  until  then. 

And  if,  after  that,  pus  is  retained,  Avhich  it  almost  constantly 
is,  in  the  long  and  tortuous  tracks  which  separate,  for  example, 
a  focus  of  dorso-lumbar  Pott's  disease  from  a  fistula  burrow- 
ing in  the  thigh  —  if  such  retention  occur,  it  will  be  almost 
impossible  to  remedy  it;  there  will  be  fever  and  septic  absor- 
ption which  will  pave  the  way  to  visceral  degenerations 
(liver  and  kidney),  culminating  in  the  death  of  the  patient, 
after  one  or  several  years. 

This  is  the  constant  result  of  surgical  operations  performed 
in  Pott's  disease  ;  I  could  quote  hundreds  of  observations  of  this 
kind,  but  each  of  you  will  have  known  such  in  his  own  circle. 

Doubtless,  the  situation  is  not  the  same  in  the  case  of 
superficial  tuberculosis,  cervical  adenitis,  iodopathic  cold 
abscess,  spina  ventosa,  ostehis  or  osteo-arthritis  easilv  accessible, 
in  Avhich  cases,  if  a  fistula  remain,  the  complete  drainage  of  it 
does  away  with  such  retention  and  reabsorption. 

But  do  not  conclude  that  operation  may  never  be  seriously 
harmful  in  cases  of  superficial  tuberculoses.  The  danger  of 
secondary  infection  does  not  exist  here,  it  is  true;  but  can  we 


2o6       GENERALISED  TUBERCULOSES  AFTER  OPERATIONS 

prevent  the  risk  already  pointed  out  of  a  tuberculous  inoculation 
in  the  course  of  an  operation,  when,  by  the  knife  or  the  cu- 
rette, the  bacilli  are  brought  in  contact  with  vascular  tissues 
thus  harrowed  and  scraped  ?  Inoculation  will  be  spread  by  a 
regional  extension  of  the  tuberculosis,  or  by  the  creation  of  a 
new  focus  at  a  distance. 

Here  are  some  examples  taken  from  a  hundred  such  cases  : 

a.  A  great  Parisian  surgeon  performed  castration  lor  an  epididymitis 
dating  back  two  years,  in  a  cliild  of  i3  years.  Soon  after  tlie  operation, 
exactly  three  months,  there  appeared  a  right  coxitis,  and  in  the  fifth  montli 
the  left  hip  followed  suit. 

b.  A  little  girl  had,  for  three  years,  a  double  Spina  ventosa  of  the 
right  hand.  It  was  decided  all  at  once  to  scrape  it  :  nine  Aveeks  later  Pott's 
disease  appeared  at  two  points  (cervical  and  lumbar). 

c.  A  young  man  24  years  of  age  was  brought  to  me  for  left  epididymitis 
by  his  brother,  who  is  a  medical  man.  I  proposed  modifying  injections 
(see  chap,  xix)  into  the  site.  The  treatment  doubtless  appeared  very  simple 
to  my  confrere  who  went  the  next  day  to  Paris,  to  consult  one  of  his  old 
masters,  a  very  distinguished  surgeon,  who  performed  castration.  Two 
months  afterwards,  the  patient  was  carried  off  by  meningitis  before  even  the 
operation  wound  was  cicatrised. 

And  I  know  of  three  other  cases  exactly  similar  to  that. 

d.  Lastly,  I  hear  from  one  of  the  surgeons  who  operate  most  frequently 
on  appendicitis  in  Paris,  that  he  has  decided  not  to  operate  again  on  appen- 
dicitis when  it  is  duty  recognised  as  being  tuberculous  —  because,  having 
operated  upon  six  such  cases,  he  had  seen  two  of  the  patients  (the  third  I) 
carried  off  some  months  after  the  operation,  by  the  onset  of  cerebral  tuber- 
culosis. 

So  much  for  the  risk  of  tuberculous  inoculations  after  ope- 
ration, a  danger  I  have  no  wish  to  exaggerate,  which  is,  I  will 
admit,  not  very  great,  but  which  cannot  be  denied  nowadays, 

We  will  take  now  the  cases  called  "  satisfactory",  those 
in  which  cure  is  obtained  by  operation;  at  what  price  is  that 
cure  obtained? 

Do  the  mutilations  produced  count  for  nothing? 

I  do  not  refer  to  the  loss  of  power  left  in  children,  by  ope- 
rations on  the  skeleton  of  their  limbs,  but  solely  to  the  results 
obtained  in  those  superficial  tuberculoses  which  appear  the 
most  justifiable  for  the  knife. 


AHSTENTION    PUEl'ERAHI.E     TO     OI'EKATION  -jq-j 

III  ii|»(i;iliiit;-  |n|-  cci'Nit'al  .nlciiilis,  \(.ii  li,i\c  junidrd  llie 
risk  (il  scplic  itilcdion"  and  luberculdiis  inoculalion,  \ovi  have 
ohiaincd  union  hy  firsl  inloiilion,  (if  wliirli  \ou  arc  sr»  |)iou(l  ; 
lull  is  il  iIrmi  iiDJliinL:-.  I  ask  iIkisc  siiriicoiis  who  operate  u|)on 
cervical  glands,  is  il  nolhing  lliat  \ou  have  left  ihal  younf 
girl  Avilh  horrible  cicatrices,  persistant  stigmata.  a\  Inch  will 
remain  Avith  her,  lo  ihe  end  of  her  davs,  a  cause  of  inliriile 
sadness,  A\hich  will  ••  mark  "  her  lor  ever,  will  prevenl  her 
establishing  herself  and  pursuing  a  normal  existence? 

And  it  is  not  a  question  only  of  fashionable  young  ladies; 
how  many  shop  girls  and  domestic  servants  who,  by  the  large 
cicatrices  on  their  necks  are  prevented  from  obtaining  situa- 
tions and  gaining  a  livelihood! 

Each  of  us  must  examine  his  conscience.  AVe  ought  to 
think  a  little  more  of  those  children  with  Pott's  disease  who  have 
paid  w  ith  their  lives  for  tlie  mistake  of  the  practitioner  who  has 
opened  their  abscesses,  or  even  more,  of  those  young  women 
with  scarred  necks,  who  have  paid  for  that  same  error  with 
their  beauty  and  their  happiness;  I  believe  that  the  thought 
would  make  us  accord,  in  course  of  time,  rather  less  credit 
to  cutting  operations  in  the  treatment  of  suppurated  tuber- 
culoses. 

Remember  that  taberciilosis  does  not  love  the  knife  which 
rarely  cures,  often  aggravates,  always  mutilates. 

2°'^  The  value  of  abstention.  Do  not  be  astonished  after 
this,  if  I  affirm  that  to  leave  suppurated  tuberculoses  alone,  to 
do  nothing  except  a  good  general  treatment,  is  far  safer,  on  the 
whole,  than  to  operate  upon  them.  In  other  words,  syste- 
matic abstention  is  preferable  to  cutting  interference 
at  all  costs. 

And  I  am  not  alone  in  this  opinion.  Has  not  a  Professor 
of  the  Faculty  of  Paris  the  habit  of  saying  that,  in  the  presence 
of  superficial  tuberculosis,  it  is  better  to  fold  ones  arms,  than 
to  take  up  the  knife?     I  have  heard  recently  the  same  language 


20b  PUNCTURE    AND    INJECTION,     THE    ONLY    RATIONAL 

at  the  Orthopoedic  Institute  at  Milan,  where  a  surgeon  said  to 
me  :  "  At  -one  time  we  operated  upon  and  scraped  every 
abscess  in  coxitis  and  Pott's  disease;  noAv,  Ave  never  touch 
them,  and  our  patients  have  gained  much  ". 

Indeed,  if  one  does  not  touch  them,  this  is  Avhat  happens  : 

P*,  A  large  number  of  these  tuberculous  suppurations  are 
reabsorbed  —  nearly  half  of  them,  a  fact  certainly  not  to  be 
overlooked  —  and  it  is  true,  not  only  in  superficial  tubercu- 
loses, but  also  in  abscesses  by  gravitation  in  Pott's  disease ;  it 
is  indeed  most  frequent  in  the  last  case. 

Nearly  half  the  abscesses  in  Pott's  disease  are  re-ab- 
sorbed spontaneously,  if  you  leave  the  subjects  at  complete  repose 
with  good  general  treatment. 

2"'^  The  others  open  spontaneously  may  be,  but  with  spon- 
taneous opening  :  (a)  the  risk  of  tuberculous  inoculation  is 
negligible,  contrary  to  what  occurs  in  scraping  and  cutting- 
operations.  (6)  The  risk  of  secondary  septic  infections  is  less 
than  in  listuloe  following  on  operative  interference,  that  is  to 
say,  fistulas  in  which  one  has  disturbed  the  tissues  very  much. 

This  is  Avhy  the  fistulas  which  are  produced  in  the  neglec- 
ted children  of  the  country  are  cured  much  more  often  than 
those  Avhich  are  subjected  to  extensive  and  learned  surgical 
interferences,  fistulae  which  are  very  often  infected  at  the  onset 
by  the  operative  act. 

(c)  Mutilation  is  less  after  spontaneous  opening  than  after 
operation. 

The  cicatrix  in  the  neck,  which  the  spontaneous  opening 
of  a  broken  down  gland  leaves,  will  never,  or  scarcely  ever,  be 
so  unsightly  as  the  large  and  horrible  scars  going  from  ear  to 
chin,  or  from  one  ear  to  other,  of  which  the  surgeons  are  so 
proud,  all  the  more  proud  as  they  are  longer. 

S"^"^  Puncture  and  Injection.  —  But  let  us  hasten  to  say 
that  Ave  have  fortunately  found  something  better  than  absten- 
tion  to   set   against  the   suppurated  tuberculosis.      If  one  sins 


TREATMENT    OF    SlITURATED    TUBERCULOSES  aO() 

cs[)ccially  gravely  by  commission  (in  operating),  one  sins  also. 
bv  omission,  in  leaving  an  abscess  lo  open  sponlancously.  ll  is 
necessar\  not  only  nol  lo  opcrale  upon  or  lo  open  tuberculous 
snp|)uralii)ns.  but  still  more  to  prevent  them  opening,  by 
punduring  ibem  witli  a  fme  needle.  And  we  will  bave  already 
lencicrcd  a  great  service  lo  our  patients  if  we  bave  saved  ibem 
IVoni  I  be  risk  of  mutilation,  septic  infection  and  tuberculous 
iiK  iculalion. 

Tbcrefore  lo  do  nolbing  sbould  not  be  your  mollo. 

There  is  a  belter  way.  If  we  know  bow  to  profit  by  tbe 
presence  of  tbe  abscess  cavity  in  order  to  replace  tiie  pus  by 
a  modifying  liquid  which  will  cure  rapidly  the  tuberculous 
wall  (idiopathic  abscess),  and  which,  in  abscesses  by  gravi 
lation,  Avill  rise  up  to  tbe  source  of  the  pus  and  cure  not  only 
the  abscess,  but  even  the  affected  bone  or  articulation  whence 
the  pus  comes,  ah!  then,  it  will  be  truly  perfect. 

AVe  shall  bave  certainly  cured  our  tuberculosis,  more  surely 
llian  with  the  best  conducted  operation,  and  we  shall  bave 
cured  it  in  a  few  months;  Ave  shall  bave  cured  it  without  any 
danger  and  without  mutilation  (tbe  most  beautiful  aesthetic 
and  orthopoedic  result).  Here  then  is  tlie  ideal  and  dreamt  of 
treatment,  until  the  anti-tuberculous  vaccine  or  serum  has 
been  discovered.  Well,  this  treatment  is  not  a  myth,  it  exists, 
as  we  have  said :  it  is  that  of  punctures  followed  by  modifying 
injections,  which  not  only  always  cure  (99  times  in  a  hundred) 
without  risk  and  Avithout  defect,  and  cure  relatively  quickly  (in 
2  or  3  months) ;  but  more,  it  offers  the  advantages  of  an  ines- 
timable prize,  it  is  very  simple  and  easy ;  and  it  may  be 
applied  by  all  medical  men.  wherever  they  may  be. 

This  is  what  one  ought  not  to  Aveary  in  repeating,  until  all 
practitioners  are  convinced,  and  until  the  treatment  is  included 
in  current  practice,  as  it  merits  to  be. 

All  medical  men  avUI  obtain  the  promised  results,  provided 
that  they  follow  exactly  the  technique  AA^e  baA^e  described.  In 
spite   of    that    technique    being   easy,    there    are   neAertbeless 

Cai.ot.  —  IrulispensaLle  ortliopedics.  i4 


2IO  DRY    TUBERCULOSES    COi\SERVATIVE    TREATMENT, 

some  details,  the  minute  observation  of  Avbicli  is  indispensable. 
I  very  often  see  practitioners  "who  wish  to  treat  by  punc- 
tures and  injections  their  suppurated  tuberculoses  and  who, 
being-  unsuccessful,  think  themselves  obliged,  in  the  end,  to 
open  or  allow  to  open,  the  purulent  collection.  That  happens 
because  their  technique  is  defective.  You  should  follow  what 
I  have  written,  in  every  detail,  in  chapter  III  :  it  Avill  give 
you  success  invariably. 

2"'  Dry  or  fungous   tuberculoses. 

The  respective  value  of  the  three  treatments  (operation, 
abstention  and  injections)  is  the  same  for  the  dry  tuberculoses  as 
for  those  which  have  suppurated  —  Avith  this  difference  however, 
that  in  the  tuberculoses  Avhich  have  suppurated,  injections  are 
of  far  greater  value  than  abstention^  and  extirpation  —  Avhilst 
there  remain  some  cases  of  dry  tuberculoses  where  the  conser- 
vative treatment  and  surgical  operation  may  be  contem- 
plated although  they  are  not,  to  my  mind,  to  be  preferred. 

It  is  not  then  a  question  here  of  proscribing  these  two  treat- 
ments but  simply  of  considering  them  as  exceptional  treatments. 

We  Avill  proceed  to  state,  in  a  few  Avords,  the  exceptional 
indications . 

The  value  of  purely  conservative  treatment.  —  This 
treatment  may  cure  a  good  number  of  dry  or  fungous  tuber- 
culoses. It  is  not  Ave,  who  live  at  Berck,  Avho  are  going  to 
contest  this.  But  it  can  only  be  relied  upon  AAhen  the  patients 
are  able  to  live  by  the  seaside  or  in  the  country;  and  AA'hen  it 
cures,  it  is  not,  generally,  until  after  a  long  time,  three,  four, 
five,  six  years,  and  even  longer;  it  is  an  inconvenience  that  all 
those  AA'ho  employ  it  are  obliged  to  recognize.  To  sum  up,  it  is 
too  long,  consequently  too  costly,  to  be  carried  out  in  all  patients. 

But  especially,  it  is  too  uncertain.      Even  under  the  best 

I.  Apart  from  the  case  of  deep  abscess  in  Pott's  disease,  where  one 
ought  to  abstain  and  wait  for  the  spontaneous  reahsorption  of  the  ahscess. 


WllimiT    INJECTIONS.     M\V     WE      M'I'IIII)    IN    A    FEW     CASES.     211 

coiulilioiis,  il  (Iocs  imI  curr  iiiiicli  iiion'  tli;m  hall  tlio  cases, 
III  llic  ollior  hall',  llie  disease  progresses,  tlic  liihcicuious  lesion 
suppurates  or  goes  on  indeliniteiy. 

These  arc  sufficient  reasons  Avh>  the  "  pure  "  conservative 
treatment  cannot  he  adopted  as  a  general  method  of  treatment. 

It  ought  to  be  rejected,  particularly  wiicn  [)alients  of  the 
woilving-classes  are  in  question,  children  or  adults,  and  in  the 
case  of  inliahilants  of  lariic  towns  who  arc  not  ahle  to  leave 
their  unheal  tin  surroundings. 

It  is  acceptable,  on  the  contrary,  for  a  child  belonging  to 
a  family  in  easy  circumstances,  who  comes  to  us,  with  a  tuber- 
culosis apparently  benign,  for  example,  a  hard  adenitis,  or  a 
subcutaneous  tuberculoma.  The  parents  are  perturbed  at  the 
ver\  suggestion  of  making  the  least  injection;  they  declare  that 
they  are  not  in  the  least  hurry,  and  that  the  question  of  duration 
is  a  secondary  consideration  to  them.  They  will  arrange  for 
the  child  to  live  at  the  sea-side  for  any  length  of  lime  it  may 
be  necessary,  three  years,  four  years,  and  more,  mider  any 
conditions  of  hygiene  and  feeding  that  may  be  prescribed. 

The  parents  are  altogether  wrong  in  dreading  injections  quite 
painless,  of  course;  but  after  all,  since  thev  are  not  always 
indispensable  for  recent  and  benign  tuberculosis,  we  can  abstain 
at  the  beginning  —  we  can  have  recourse  to  injections,  when 
the  families  themselves  have  exhausted  their  patience,  or  the 
malady  becoming  apparently  permanent,  the  proof  will  be 
manifest  to  everybody  of  the  insufficiency  of  pure  conservative 
treatment  in  this  particular  case. 

The  Value  of  Operative  Treatment.  —  As  to  the  Opera- 
tive treatment  of  dry  tuberculosis,  a  treatment  which  is  still 
unfortunately  that  of  most  surgeons,  we  must  not  forget  that, 
if  it  cure  sometimes,  it  aggravates  the  condition  often  and 
mutilates  always. 

AVe  have  already  pointed  out  the  sad  mutilations  caused  by 
the  removal  of  cervical  glands.  Me  Avill  take  another  example. 


212  DRY  OR  FUNGOUS  TUBERCULOSES 

that  of  white  swelling  of  the  knee.  \A  e  will  not  mention 
amputation,  which  must  be  considered  as  a  catastrophe,  but 
only  resection. 

One  ought  always  to  reject  resection  for  subjects  who 
have  not  completed  their  growth.  Everybody  will  agree  that 
if  it  is  economic,  it  is  insufficient  to  cure  the  focus,  and  that  it 
may,  among  other  things,  leave  a  fistula.  Performed  extensively, 
it  seriously  mutilates  the  subject  by  doing  away  with  the  arti- 
cular cartilage,  and  that  mutilation  cannot  but  be  aggravated 
later  on.  It  is  thus  that  subjects,  resected  in  their  childhood, 
present  at  manhood  lo  or  even  i5  cm.  of  shortening. 

Although  the  inconvenience  of  arresting  the  growth  in  an 
adult  does  not  exist,  it  remains  that,  in  the  adult  as  in  the  child, 
cutting  operations  performed  to  get  rid  of  the  tuberculosis  carry 
with  them  the  risks  of  permanent  fistula,  without  counting  the 
slight  danger  of  bacillary  generalisation. 

Nevertheless,  operative  treatment  is  admissible  in  some 
special  cases,  for  example  that  of  the  adult  workman  suffering 
with  dry  and  fungous  white  swelling  of  the  knee.  There 
is  here  no  question  of  growth,  which  might  arrest  us  in  such  a 
case.  On  the  other  hand,  this  man  is  obliged  to  return  to 
his  work.  Instead  of  applying  to  him  the  ordinary  treatment 
of  modifying  injections,  wdiich  would  take  from  eight  to  tw^elve 
months  to  effect  a  cure,  very  often  with  ankylosis,  Ave  may  resect 
at  once  ;  the  resection  gives  us  an  equivalent  functional  result, 
and  reduces  the  duration  of  the  treatment  by  one  half,  pro- 
vided however,  that  all  goes  well,  that  is,  if  after  having 
removed  the  whole  of  the  contaminated  tissues,  we  have  obtain- 
ed re-union  by  first  intention  \ 

I .  It  would  be  the  same  in  a  case  of  tul^erculous  lesion  of  the  soft  tissues, 
easy  to  isolate,  where  extirpation  can  be  efTected  very  completely  without 
danger  of  fistula  or  visible  cicatrix  (that  is,  in  an  unexposed  situation ;  for 
example,  an  axillary  or  inguinal  adenitis,  or  a  subcutaneous  tuberculoma  in  a 
working  man. 

But  it  is  still  preferable,  in  the  last  case,  to  abstain  from  all  operation  and 
to  allow  matters  to  go  on,  keeping  the  subject  under  observation;   he  might 


oi>i;u\rivt:  TUi:ATMt:M'   :    indications  2ii> 

Oulsiclo  tlicse  cxcoplioiKil  iiulicalioiis,  \vr  alwjiys  I'all  back  upon 
tlie  injoclioiis  in  iIil'  Ircalnieul  ul"  liardaiul  runguus  luberculosc-s. 

Injections  the  best  Treatment  for  dry  Tuberculoses. 

How  are  injections  able  to  cure  dry  tuberculoses  ? 

'riioi'c  are  t\\o  melliods  of  cure  of  lubcrculou.s  lesions  :  ibc 
sclerosing  transformation,  and  the  soflening,  wilb  sabsef[uriiL 
evacuation. 

The  injections  act  in  bringing  about  one  or  other  of  these 
modifications. 

They  cure  sometimes  hke  the  purely  conservative  treatment, 
sometimes  like  the  surgical  treatment ;  that  is,  by  iiardening  the 
fungosities,  or  by  liquifying  them,  by  which  means  their  expulsion 
out  of  the  organism  is  rendered  possible  (by  means  of  puncture). 

This  depends  upon  the  liquid  injected. 

The  llrst  method  of  cure  is  carried  out  by  injections  of  the 
"  dry  type  ";  that  is,  those  which  do  not  produce  softening; 
for  example,  iodoform  and  creosote. 

The  second  by  injections  of  the  "■  liquid  type  "  ,  those 
which  cause  softening  of  the  fungosities  and  the  formation  of 
an  effusion ;  for  example,  naphtol  camphor. 

The  injections  of  the  liquid  type  are  most  efficacious  and 
certain,  because  they  permit  of  the  complete  evacuation  of  the 
tuberculous  products  by  the  very  small  orifice  of  an  aspira ting- 
needle,  without  any  risk  of  fistula  or  tuberculous  generalisation 
which  always  follows  in  the  train  of  surgical  operations. 

It  is  therefore  the  most  rational  treatment,  that  wliicli 
accords  best  with  the  indications  of  bacteriology  and  of  clinical 
surgery  :  the  first  calls  for  the  expulsion  of  the  tuberculous 
products  out  of  the  body,  the  second  demands  that  it  should 
be  done  without  any  damage  to  the  patient ;  —  a  treatment 
which  has  already  been  put  to  the  test  in  several  thousands  of 
cases  —  a  treatment,  simple,  although  very  minute. 

even  continue  at  liis  worli.  Either  tlae  lesion  is  reabsorijed ,  or  it  softens  spon- 
taneously, in  which  case  one  would  immediately  perform  the  puncture. 


2l4  DRY   TUBERCULOSES.    THEIR   ARTIFICIAL    SOFTENING 

Ah,  yes!  very  minute;  and  we  ought  to  repeat  as  to  the 
injections  what  Ave  have  ah-eady  said  as  to  the  punctures, 
namely,  that  tlie  treatment  demands,  in  order  to  give  the 
promised  results,  to  be  done  according  to  a  perfect  technique 
and  not  anyhow,  as  if  the  liquid,  the  dose  of  the  liquid,  the 
number  of  injections,  Avere  of  no  importance.  The  number  of 
injections  may  be  from  12  to  i5  —  this  means  that  the  treat- 
ment is  somewhat  exacting. 

A  slight  inconvenience,  on  the  whole,  if  one  has  regard  to 
the  advantage  and  the  results !  HoAvever,  and  once  again,  cure 
is  the  prize  I      And  «  where  there's  a  aaIII,  there's  a  Avay  ». 

We  have  already  given  the  details  of  the  technique,  Avith 
all  desirable  precision,  on  page  i65,  and  aac  aaIII  return  to  it  a 
propos  of  the  treatment  of  dry  or  fungous  tuberculous  arthri- 
tis (page  Boo)  and  a  propos  of  the  treatment  of  hard  adenites 
and  cutaneous  or  subcutaneous  tuberculomata  (chapters  XVIII 
and  XIX). 


APPENDIX 

On  our  Method  of  Softening  artificially  the  Dry 
and  Fungous  Tuberculoses. 

(Its  Principles  ;  its  Practical  Realization.) 

I.   —    The  Question  of  Principle. 

It  is  admitted  that  suppurated  tuberculosis  is  essentially  of 
graver  import  than  dry  or  fungous  tuberculosis.  We  agree  with 
that* ;  but  on  the  other  hand,  it  is  certain  that  Ave  are  to-day  better 
armed  against  suppurated  tuberculosis  than  against  dry  tuberculo- 
sis; so  that,  in  fact,  there  is  more  than  compensation,  and,  on 
the  Avhole  it  Avould  be  better  to  have  a  cold  abscess  than  a  tuber- 
culoma. 

I.  In  spite  of  the  fact  that  this  may  not  be  absolute,  nor  applicable  to  all 
cases  (as  we  have  already  shewn  in  our  hook  :  Les  Maladies^  qu'on  soigne  a 
Berck,  pp.  70  and  80,  to  which  we  refer  you  for  this  discussion). 


SOl'ir.MNt;     Ol"    l-L.NCiOSlTll-S    l!i:iN(;     OlilVIM'.l),     rL.NCTLUK         M.) 

I    w  ill  explain  niNScIf. 

\  \iiimi;  laiK  (MUM'  lo  iiii'  willi  a  sii|)|iiMa  I  iiii;  ailiMiilis ;  lliis,  \VC 
kiK^w  N\i'  tail  ciiic  (will)  |mnciui'cs)  in  a  lew  wocks,  complclcly, 
willioiil  luutilalioii  anil  williout  cicatrix. 

\s  a  set  oil',  a  second  young  lady  came  having  a  "  sini|)l(; 
haril  adenitis,  lor  wliicli  A\e  notice,  as  liappens  too  often,  every 
tliin"-  lias  been  useless;  nothing  succeeds  :  neither  the  sojourn  at 
Bcrclc  I'or  a  year  or  two.  nor  the  well-known  medicines,  nor  sclero- 
sing injections  of  creosote  and  iodoform.  This  hard  adenitis  would 
not  he  cured.  It  remained  only  to  operate  upon  it,  hut  o[)eration 
mutilates,  operation  leaves  an  unsightly  cicatrix  which  is,  in  the 
eyes  of  the  ^vorld,  the  infamous  and  inell'aceahle  sign  of  scrofula. 

You  see,  when  all  comes  to  all,  the  fate  of  the  hrst  young  lady, 
with  her  cervical  ahscess,  is  much  more  enviahle  than  that  ol  the 
second,  Avith  her  hardened  gland,  so-called  more  benign. 

In  the  presence  of  this  hard,  persisting  adenitis,  one  cannot 
but  regret  that  it  would  not  suppurate.  There  would  have  been, 
bv  the  fact  of  its  suppurating,  more  to  gain  than  to  lose  for  a 
patient  treated  by  a  medical  man  know  ing  how  to  make  a  puncture. 

But  alas!  in  spite  of  all  our  desires  the  adenitis  would  not  sup- 
purate at  all. 

Why  not  force  it  to  do  so?  Why  not  force  this  tuberculous 
<dand,  and  further  than  that,  all  the  hard  tuberculoses,  to  soften 
artificially  :  synovites,  osteo-arthritis,  epididymitis,  which  ^^l\\  not 
reabsorb?  Yes,  let  us  seek  for  the  suppuration  of  the  tuherculo- 
mata.  That  is  what  we  dared  to  say  20  years  ago  I  —  we  were  told 
then  that  it  would  be  madness. 

We  have  prosecuted  the  practical  realisation  of  our  ideas. 

II.  —   The  Technical  Problem  to  Solve. 

Artificial  softening  of  hard  tuberculoses  without  injurN  to  the 
patient  is  a  problem  difficult  to  solve,  of  which  you  see  very  well 
there  are  two  terms  :  to  act  upon  the  tuberculous  lesion  with 
extreme  energy,  since  it  is  nothing  less  than  making  it  pass  from  a 
solid  into  a  liquid  condition,  but,  however,  with  extreme  precision, 
so  as  to  limit  the  action  to  the  gland  or  the  lesion,  without  ulcera- 
tion and  AAithout  visible  traces. 

In  order  to  do  this,  we  have  tried  everything. 

1^'.  The  local  application  of  all  the  remedies  solid  and  liquid 
so-called  fondants  and  maturatives  :  pommades,  oinlmenls,  various 
cataplasms,  compresses  of  sea  water  hot  and  cold,  thermal  and  min- 


2l6  DRY    TUBERCULOSES.    THEIR    ARTIFICIAL    SOFTENING 

eral  "waters,  balneo-tlierapy,  radio-tlierapv,  electricllv  in  every 
form.  But  the  results  obtained  bv  these  means  have  not  been 
truly  satisfactory. 

2"''.  All  the  internal  medicines  conceivable  :  tincture  of 
iodine,  Fowler's  solution,  alcoholic  extract  of  -water  hemlock,  that 
in  particular,  because  Bazin  said  so  :  "■  in  small  doses  the  hemlock 
may  cause  the  reabsorption  of  tuberculous  glands  :  or  by  raising 
the  dose,  their  softening  ".  Hoav  precious  it  -would  be  -were  it 
true !  Unfortunately,  this  medicine  has  not  given  us  the  promised 
results. 

S"'.  We  then  attempted,  with  needles,  the  discission  of  the 
gland  (as  proposed  for  cataracts)  in  oi'der  to  prepare  and  facilitate 
its  ultimate  softening  or  reabsorption.  We  tried  to  break  up  the 
tuberculoma  -with  fine  curettes,  Avith  cutting  blades  in  the  form  of 
scissors,  introduced  closed  and  then  opened.  But  the  results  Avere 
incomplete,  and,  on  the  other  hand,  the  passage  and  manoeuvring 
of  these  cutting  instruments  left  visible  traces  on  the  skin. 

4"'.  Intra- glandular  injections  of  innumerable  different 
substances  :  tincture  of  iodine,  salt  Avater,  either  mineral  or  thermal, 
solution  of  chloride  of  zinc,  culture  of  staphylococcus  and  of 
streptococcus,  previously  sterilized,  tuberculine  (on  the  advice  of 
Professor  Calmette).  We  have  tried  to  produce  the  digestion  of  the 
gland  parenchyma  by  injections  of  pepsin  and  particularly  of  pan- 
creatine (because  this  acts  in  a  neutral  medium).  But  it  is  almost 
impossible,  for  instance,  to  have  solutions  of  pancreatine  at  the  same 
time  quite  aseptic  and  moreover  active.  Injection  of  oil  of  turpen- 
tine yields,  it  is  true,  about  the  third  or  fourth  day,  some  aseptic 
suppuration,  but  it  is  extremely  painful  and  often  causes  scars. 
We  have  injected  the  Avhole  series  of  camphorated  phenols;  naphtol, 
gaiacol,  thvmol,  salol,  camphor,  sulforiclnated  phenol,  etc.,  but 
the  injections  did  not  produce  softening  or  they  ulcerated  the  skin. 

Finally,  that  Avhich  did  best  in  bringing  about  the  result  Avere  tbe 
injections  already  indicated  in  the  chapter  on  technique,  p.  i64  ; 
namely,  for  the  treatment  of  fungous  arthritis,  injections  of  naphtol, 
camphor  and  glvcerine,  and  for  the  treatment  of  a  small  tubercu- 
loma and  adenites,  injections  of  our  fondant  of  four  liquids,  mixed 
in  equal  parts,  of  sulforicinated  phenol,  camphorated  phenol,  cam- 
phorated naphtol,  oil  of  turpentine.  You  Avill  find  on  pp.  i65  and 
i68,  the  method  of  using  the  one  or  the  other  of  these  "  fondants  ". 

To  recapitulate  :  our  method  consists  in  transforming  the  hard 
adenites  and  tuberculomata   into   small   cold    abscesses,    \\hicli  are 


FISTLL  !•:,    WOLNnS    AM)    TLHEIICL  LOL  S    LLCEU.VTIONS  '2l~ 

llien  puncluioil  :  in  allcriiig  IuIktcuIous  ailliiitis,  by  clicmical 
curollago  of  the  lunyosilics  on  llic  internal  surface  ol'  llie  synovial 
mLMnbrano  (llic  curcltage  realised  hv  our  injections)  into  hydrar- 
lliioses  or  pvarlhroses.  which  are  treated  afterwards  as  common 
coUrabscesses. 

Therefore,  cold  abscess,  that  enemy  formerly  so  terrible,  has 
been  changed  by  us  into  a  very  precious  auxiliary,  which  allows  us 
to  predict  and  ensure  the  cure  of  external  tuberculoses.  And  you 
understand  now  in  what  sense  we  were  able  to  say  :  A\  hen  cold 
abscess  does  not  exist,  invent  it...  create  it. 

We  Avill  return,  in  the  course  of  this  book,  to  the  divers  appli- 
cations of  this  doctrine,  everywhere  accepted  and  applied  today ; 
but  we  sav  now,  that  we  have  gained  the  most  beautiful  results, 
results  which  theorv  promised  (see  p.  498,  Statistics  of  >\  liite 
Swellings,  as  treated  at  our  Hospital  Cazin  at  Berck).  See  also 
"  rObservation  Clinique  "  in  the  Appendix  to  Chap.  XVIII 
(Adenites) . 


Tuberculous  Fistulas,  and  Tuberculous 
Wounds  or  Ulcers* 

^Miat  we  are  about  to  say  here  is  applicable  to  all  tuber- 
culous fistulse. 

As  to  the  peculiarities  of  each  fistula,  they  will  be  studied 
in  the  chapter  devoted  to  each  external  tuberculosis  (see  Pott's 
disease,  white  swelling,  adenitis,  osteitis,  epididymitis,  etc.). 

Fistula  proceeds  from  the  opening  —  surgical  or  sponta- 
neous —  of  a  tuberculous  focus.  Fistula  is  the  enemy  and 
the  black  spot  in  external  tuberculoses  :  it  is  the  nightmare  of 
all  those  who  are  occupied  with  these  affections. 

If  we  have  condemned  operative  treatment  for  almost  the 
whole  of  the  cases  of  external  tuberculosis,  it  is  because  opera- 
tion so  often  leaves  a  fistula  behind  it. 

If  we  have  described  with  so  many  minuticC  tlie  technique 
of  puncture  and  injection,  it  was  so  that  you  might  be  able  to 
avoid  fistuUe. 


210  TUBERCULOCS   FISTUL.E,    WOU>DS,    AND    ULCERS 

For  fisluloe  are  so  difficult  to  cure  that  the  preventive 
treatment  remains  the  best. 

It  is  for  this  reason  lliat  I  avouIcI  have  tlie  folloAving  ins- 
cription graved  on  tlie  front  of  liospitals  ^vliere  the  external 
tuberculoses  are  treated  : 

«  The  cure  of  closed  tuberculoses  is  certain.  To  open 
tuberculoses  or  to  allow  them  to  open  is  to  make  a  way 
through  which,  very  often,  death  will  enter.  » 

The  danger  of  death  may  be  but  slight,  except  in  the  symp- 
tomatic fistulas  of  deep  osseous  and  articular  lesions  (and  more 
particularly  in  hip  chscase  and  especially  Pott's  disease).  But 
the  superficial  fistulas  themselves  are  always  troublesome,  not 
only  by  the  unpleasantness  Avhich  every  persistent  suppuration 
causes,  but  still  more  by  the  mutilations  and  blemishes  which 
they  may  leave  behind  them.  For  example,  the  hideous  and 
indelible  cicatrices  left  by  glandular  fistula?  in  the  cervical 
region,  Avithout  reckoning  the  risk  of  inoculation  (if  it  be  but 
small)  springing  from  the  persistence  of  an  active  tuberculous 
focus,  even  when  superficial. 

Nevertheless,  if  among  fistuke  there  are  certain  which  kill, 
whilst  others  are  merely  disagreeable  (with,  between  the  two, 
every  degree  of  gravity)  a  classification  of  the  different  varieties 
has  to  be  made. 

Classification  of  Tuberculous  Wounds  and  Fistulse. 

1.  Tuberculous  wounds  and  ulcerations  of  the  skix\ 

2.  Symptomatic  fistulse  or  lesions  of  soft  tissues. 

3.  Symptomatic  fistulse  of  osseous  and  articular,  but 
SUPERFICIAL,  lesions  (that  is,  where  drainage  is  easy). 

[x.  Symptomatic  fistulse  of  osseous  or  articular  lesions, 
but  DEEP  (that  is,  where  drainage  is  difficult). 

P^  Qroup.  —  Tuberculous  Wounds  and  Ulcerations 
of  the  Skin.  —  It  is  a  question  here  of  lesions  on  the  surface 
rather  than  real  fistulae,  for  there  is  not  any  track  leading 
from  the  cutaneous  opening,  or,  if  sometimes,  a  sinus  exists,  it 


ClASSll'ICM  ION    I.     IL  lilCHCLI.OUS    WolMiS    (WllIKH   T    SINLs)        2  I  (J 

remains  siihciilanoons   llin)iiL;li   ils  wlmlc   Iciif^lli.    il  is  a    siiiipic 


Fis. 


Tuberculous    ulceration     of     the       tig-  177  ''«•    —   The  process  of 


skin  :  a  large  orifice,  >Yilh  exuberant  fleshy 
granulations  protruding;  margins  of  a  violet 
colour,  skin  delicate,  sloughy  (a  probe  has  been 
introduced  to  raise  itj ;  the  adjoining  tissues 
are  uneven,  lumpy. 


cicatrisation ;  the  ulceration 
dried,  covered  with  a  greyish 
or  blackish  crust,  which  per- 
sists; the  integument  around 
remains  for  along  time  lumpy 
and  coloured. 


undermining    of   llie   skin  (rallier   than  a  true  fislulous  track). 


Fig.  17S   and  178  bis.  —  Types  of  syphilitic    gummatous   ulceration,   surrounded    kv 
sharply  cut  perpendicular  edges. 

These  avouikIs  follow  cutaneous  or  sab-culaneous  tuberculo- 


220 


TUBERCULOUS   FISTULE.    -WOUXDs 


AND    ULCERATION'S 


mala.  \o\\  well  know  the  typical  characteristics  of  these 
wounds,  namely  :  their  edges  are  thin,  violet  coloured,  irregu- 
lar, undermined,  their  bases  yellowish,  with  small  caseous  points 
or  fungosities  (fig.   177  and  177  his.). 

AYhilst  syphilitic  sores  have  rounded  edges  —  cut  perpendi- 


Fig.  I'jg.  —  Keloid  patcli  in  the  cervical  region  proceeding  from  the  opening  of  sub-- 
cutaneous-bacillary  gummata,  and  sut>-axillary  ulcers  of  glandular  origin.  The 
fistula?  were  produced  before  the  patient's  arrival. 

cularly  —  punched  out  —  cliiT-like,  with  a  base  the  colour  of 
ham,  or  of  a  gummy  appearance  (fig.   178  and  178  bis.) 

But,  fairly  often,  these  differential  characteristics  are  much 
less  definite,  confusion  is  possible  between  the  two,  so  much 
so,  that  there  are  mixed  forms,  "  scrofulates  de  verole  ". 

Even  Avhile  still  in   the  domain   of  tuberculous  lesions,  one 


DTAHNOSIS    or    TlPERClI.Ol  S    AM)    S'il'lllMHC    SOKES  221 

i-aii  see  interniedialc  I'diius  hdwci'ii  Itacillarx  ulcers  of  llie 
skin  and  lubcrculous  liij)us. 

However,  MC  will  have  (lie  oji|)orlunil\  in  another  pari  of  this 
wnik  (V.  chap.  \i\)  of  speaking  ahunl  iiihiMCiilosis  of  the  skin. 

2'"'  Group. —  In  I  hi- l:i-i  iiip,  and  in  I  he  fi  ijluw  ing  ones,  it  is 


Fig.  i8o.  —  Ulcers  following  the  spontaneous  opening  of  bacillary  glands,  which 
occurred  before  arriving  at  Berck.  The  fistula-  have  been  cured  in  three  months 
bv  injection. 


a  question  of  true  fistula*,  that  is,  sores  Avliicli  are  nothing 
more  than  small  craters  through  Avhich,  coming  to  open 
through  the  skin,  are  tracks  and  deep  cavities,  and  ending  in 
tuberculous  lesions  of  the  soft  tissues  or  CAen  of  the  skeleton. 


222    FISTUL-E    PROCEEDING   FROM    TUBERCULOSIS   OF   THE    SOFT   TISSUES 

The  second  group  is  thai  of  fistuke,  symptomatic  of  lesions 
of  the  soft  parts. 

For  example,  fislulc'e  of  the  neck,  of  the  axilla,  of  the  groin, 
symptomatic   of  a  tabercidous  adenitis  (fig.  179  and  180).      Or 


Fig.  181.  —  Fislul->a5  opening  from  a  tuberculosis  of  the  testicle  opened  spontane- 
ously; this  figure  shows  the  state  of  the  lesion  after  a  stay  at  Berck.  On  his  arri- 
val, the  patient  had  two  other  fistulsc  on  the  right  side  of  the  scrotum  still  larger 
and  with  a  graver  appearance;  we  have  cured  them  by  the  paste  injections.  Those 
on  the  left  side  "  dragged  along  »  hut  are  in  a  good  way  towards  cicatrisation  and 
no  doubt  complete  cure  without  operation  .  The  unusual  delay  in  the  cure  of 
these  last  fistula;  is  explained  by  the  co- existence  in  the  patient  of  Pott's  disease 
and  a  suppurating  costal  osteitis.  But.  in  spite  of  the  multiplicitv  of  tuberculous 
localisations,  the  patient  is  so  much  ameliorated  and  transformed,  that  his  complete 
cure  is  certain  and  is  only  a  matter  of  time  ;  about  another  year's  stav  at  Berck 
and  local  treatment. 

Let  us  say  on  this  subject  that  all  the  Other  scrotal  fistulae,  C5  fistulae  out  of 
•200  cases  of  tuberculosis  of  the  testicle  or  of  the  epididymis  (which  we  have  seen 
during  i8  years)  have  been  cured  by  my  injectious  in  a  period  which  has  varied 
from  one  month  to  a  year.  The  case  here  represented  has  been  by  far  the  longest 
of  all  to  cure.  The  cure  of  this  patient  is  to-day  complete.  See  end  of  this  obser- 
vation in  Additional  Xotes,  p.   loio.  , 


fistulfc    of   the    scrotum,    symptomatic    of  an    epididymitis 
hacillary  orchitis  (fig.  181). 


or 


.">""    IM^^II  I  r.    I'lVDHLCEl)    ItY    SLIMUl  ICIVI,    osri;:ri> 


2:>:i 


Or,  fislul.r  (if  llic  hand  or  of  llic  \\risl,  SMiiplomalic  of  a 
funrfoiis  sviioritia  of  the  tendons,  or  of  a  liihcrculosis  of  llic  sy- 
noriul  sheath. 

The  3'  Group  comprises  the  symptomatic  fislulac  of  tuber- 
culous lesions  of  (he  skeleton,  hut  superficial  lesions,  that  is, 
fistuUu  with  short  tracks,  \vliicii  can  be,  consequently,  easily 
and  completely  drained. 


Fig.   182.  —  Osseous  fistula-   and    deformity  resulting   from   scraping  a   spina  ventosa 
the  scraping  was  done  by  another  surgeon  . 

For  example,  the  symptomatic  fislula-  of  a  spina  ventosa  of 
the  fingers  or  toes;  a  tuberculosis  of  the  malar  bone,  of  the 
frontal  hone,  of  the  maxillie,  of  the  clavicles,  of  the  ribs,  etc. 

In  this  group  come  again  the  symptomatic  fistulae  of  super- 


224 


^Tii   PISXUL.E    ARISOG    FROM   DEEP    OSTEITIS 


ficial  osteo-arthritis,  that  is,  almost  the  Avhole  of  the  fistula;  of 
the  elboiu,  of  the  lorist,  of  the  instep,  of  the  shoulder,  of  the 
knee. 

This  group  also  includes  a  certain  number  of  fistuloe  of 
Pott's  disease,  those  which  realise,  from  the  point  of  view  of 
facility   of  drainage,  the   conditions  aforesaid,  namely,  fistulas 


Fig.  i83.  —  Post-operative  fistulae  following  resection  of  a  rib  for  tuberculosis.  Pleu- 
ral infection  consecutive  to  tbe  operation.  (The  operation  had  been  performed 
before  the  patient's  admission  to  our  hospital.) 


which  open  on  the  neck,  or  on  the  back  at,  a  point  very  near  to 
the  vertebral  focus. 

The  4'''  Group  embraces  the  symptomatic  fistuke  of  tuber- 
culosis  of  the    skeleton,  but  of  a   deep  tuberculosis,   that  is. 


ni()f;N(^sis   OK  Tin;  I(jlu  v.viui-iil;s  oi    i  l  liLucLi.oL.s   itsili.  i-; 


220 


fistula- wilh  a  loriir  sinus —  where  llie  drainage  may   be  nmcli 

more  clillicuU  lliaii  in  llie  [)teccding  lisluhe. 

For   example,  I  he   symplomalic  lislula)   of  lii[)  disease,  (he 

fisUiliu  o( Poll's  disease,  apart  I'roiii  the  exception  menlioned  above. 
And,  on  the  other  liand,  there  may  be  exceptionally  placed 

in  this  group  certain  sympto- 
matic fistula'  of  white  swelling 
of  tbe  knee,  of  tbe  shoulder,  of 
the  wrist,  of  the  instep  —  na- 
mely, those  fistuloe  Avhich  have 
a  long  and  tortuous  track,  ren- 
dering drainage  and  the  dis- 
charge of  pus  particularly  dif- 
ficult. 

Prognosis. 

The  first  three  are  curable, 
the  fourlli  nol  always  —  far 
from  it. 

AAhy.^  It  is  because  fistu- 
la? of  the  first  three  varieties 
are  not  "  infected  ",  or  because 
their  infection  yields  easily  to 
the  means  of  treatment,  Avhilst 
the  fistulae  of  the  fourth  group  are  very  often  infecferL  infection 
super-added  and  so  grave  that  we  cannot  always  master  it. 

Therefore,  that  which  constitutes  the  gravity  of  a  tuberculous 
fistula  is  its  possible  infection;  and  the  first  question  to  put,  in 
the  presence  of  a  fistula,  in  order  to  establish  its  prognosis  and 
its  treatment,  is  Avhether  or  not  it  is  infected. 

Infected  you  may  say  it  is,  Avhen  the  primitive  tubercle 
bacilli  are  associated  with  septic  germs  which  have  come  from 
without. 

The  tuberculo-septic  pus  has  been  retained  —  which  is 
somewhat   rare   in  fistulce   of  the  first    three  groups,   but  very 

CvLOT.  —  Indispensable  orthopedics.  i5 


Fig.  i8i.  —  Eslensive  fistulous  ulce- 
ration communicating  with  tlie  shoul- 
der joint  (the  fistulff  existed  before 
the  patient's  arrival  at  Berck). 


226 


TUBERCCLOUS   FISTUL.E.    PROGNOSIS    1>    EACH   CASE 


frequent  in  the  anfractuous  and  deep  sinuses  of  those  of  the 
fourth  group  —  pus,  I  say,  will  be  reabsorbed  by  the  organism, 
it  Avill  cause  fever  and  poison  the  patient. 

If  the  duration  of  the  retention  and  absorption  is  short  the 
patient  Avill  recover. 

But  if  it  is  prolonged,  it  will  lead  to   a  progressive  intoxi- 


Fig.  i85.  —  The  same  (back  view). 


cation  of  the  organism,  a  real  chronic  septicaemia  with  degene- 
ration of  the  liver  and  kidneys.  And  the  ending  of  the  infec- 
tion of  the  fistula  will  mean  the  death  of  the  patient,  a  consum- 
mation more  or  less  distant,  Avhich  may  be  measured  by 
months  or  even  several  years. 

Fortunately,  Ave  repeat  it,  all  the  initial  infections  do  not 
end  in  this  way. 

We  are  able  to  distinguish  three  degrees  or  phases  in  infection . 


THE   NOX-INFECTKII    IISTI  F.  F.    AIIE   CL11AHLF, 


227 


The  first  degree  is  characterised  by  an  evening  rise  of  lempe- 
r.ilurc  with  morning  remissions;  the  fever  has  appeared  only 
lor  a  lew  davs  or  a  few  weeks  ;  analysis  does  not  yet  reveal 
any  trace  of  alhumeii  in  the  urine. 

The  second  degree   is  characterised  hy  the  appearance  of  a 


t^io-.  1 80.  — -  Ulceration  of  the  anterior  surface  of  the  tibia.  The  clinical  signs  on  the 
arrival  of  the  patient,  as  well  as  the  radiographic  examination,  suggest  almost  the 
diai^nosis  of  osteo-sarcoma  of  an  osteo-sarcoma,  mind  you  .  But  the  bacteriologi- 
cal examination  (bj  M.  Noel  Fiessinger)  revealed  the  presence  of  Koch's  bacillus. 
Cicatrisation  is  now  obtained.  See  end  of  this  observation  in  additional  notes, 
p.  ioi3. 

little  alhiimen;  and  the  albumen  appears,  as  a  rule,  when  the 
fever  persists  beyond  a  few  weeks. 

The  third  degree  is  characterised  hy  the  presence  of  a 
notable  amount  of  albumen  and  by  an  appreciable  hypertrophy 
of  the  liver,  which  reaches  to  at  least  a  fmger's  breadth  below 
the  false  ribs.      Fever  may  no  longer  exist  at  this  moment. 

Besides  these  principal  signs  there  are  others,  those  Avhich 
constitute  the  symptomatic  cortege  of  slow  intoxication  of  the 
organism,  namely  :  loss  of  appetite,  loss  of  strength,  wasting, 
pallor,  a  yellow  or  dirty-white  tint  of  the  face,  fetor  of  th  ^  pus, 
the  appearance  of  partial  or  generalised  oedema,  etc.,  etc. 


228 


INFECTED   FISTULE   ARE    OFTE>f    FATAL 


As  to  the  prognosis  of  infected  Jistahe,  this  differs  according 
to  the  degree  of  infection. 

The  first  two  degrees  are  curable,  provided  that  you  succeed 
—  by  proper  drainage  —  in  overcoming  the  retention  of  pus. 

Unfortunately,  perfect  drainage  is  not  always  realisablein  Pott's 
disease  or  hip  disease;  it  is  for  this  reason  that  one  cannot  pro- 


Fig.  187.  —  Osteo  articular  tuberculosis  of  tlie  knee.  The  coadition  of  the  patient 
on  his  arrival  at  Berck.  Lesions  extremely  advanced,  accompanied  by  profuse  and 
fetid  suppuration.  General  infection  of  the  organism,  evening  fever,  albuminuria, 
cachexia.  Immediate  amputation  Avas  the  last  chance  (a  very  small  one!)  of  safety 
to  resort  to;  the  parents  refused.  The  little  patient  returned  to  his  home  and  suc- 
cumbed in  two  months. 


mise,  in  an  absolute  way,   the  cure  of  an  infected  fistula,  even 
of  the  first  degree,  symptomatic  of  hip  disease  or  Potts'  disease. 
Sometimes  the  fistula  will  progress,  m  spite  of  all  our  efforts, 
to  the  3'''  degree. 

And,  in  the  third  degree,  the  disease  is  without  remedy,  or 
pretty  nearly  so,  when  albumen  exists  in  notable  quantity;  when 
the  liver  extends  two  fingers'  breadth  beyond  the  costal  margin, 
it  is  too  late.  Then,  even  if  one  drains  extensively,  even  if 
one  succeeds  in  producing  a  fall  in  the  patient's  temperature,  the 
visceral  lesions  will  continue  to  progress  to  their  full  extent  and 
will  finish  by  carrying  off" the  patient...  always  or  nearly  always. 


iiil;  itKsi    I  Ki:  \  i'\ii;m'  or   ri  ifi.ui:i  ijjl.s   risrui.r.  220 


The  Treatment. 

Every  six  months  you  will  hear  vaunted  a   new    treatment, 
so-called  marvellous,  of  tul)erculous  fistnlu'. 


Fig.  i88.  —  Operalion  sores  and  fistula?  resulting  from  surgical  interference  in  a  case 
of  hip  flisease  with  a  closed  abscess.  The  patient  liad  no  fistula'  before  the  opera- 
tion, which  ought  to  have  been,  according  to  tlie  promise  of  the  surgeon,  «  a  ra- 
dical cure  »;  it  has  left  28  fisluke  (existing  since  the  operation).  AVe  have  already 
closed  i.'i  with  our  injections.  Tea  months  later  only  three  insignificant  fistulae 
remain;  the  weight  of  the  patient  has  nearly  doubled.  (See  this  observation  in 
(I  Additional  Notes  »,  p.   ioi/|.) 

All  these  treatments,  neAv  and  old,  may  he  arranged  in  four 
groups  :  surgical  operation,  abstention,  physio-therapeutic  treat- 
ments and  injections. 


ado  TREATMENT    OF    TUBERCULOUS   FISTULE 

a.  Operation.  —  For  a  good  number  of  surgeons  (for  the 
greatest  number,  I  should  say)  the  only  rational  treatment  of 
tuberculous  fistulee  remains,  today  as  yesterday,  surgical  ope- 
ration, an  operation  which  they  perform  very  extensively  and 
which  they  repeat  without  wearying. 

Certainly  it  appears,  a  priori,  logical  and  rational.  But  in 
fact  and  in  practice,  experience  has  proved  to  us  that  operation 


Fig.  189.  —  Another  case  of  post-operative  fistulas.  This  patient  arrived  at  Berck  in 
this  condition  with  fever,  albuminuria  (8  or  10  grammes  a  day)  large  liver,  general 
cachexia ;  he  lived  two  years  longer.     He  succumbed  lately  after  an  uraemic  crisis. 

has  done  twenty  times  more  harm  than  good.  Instead  of 
destroying  by  a  single  stroke  the  tuberculous  focus  as  had  been 
hoped,  one  might  say,  as  a  general  rule,  they  stirred  up  the 
focus  and  thereby  opened  up  tissues  Avhich  until  then  were 
sound;  it  does  not  cure  the  patient,  it  mutilates  him. 

I  say  nothing  of  inoculation  far  away  in  the  meninges  or 
in  the  viscera,  and  of  tuberculous  generalisations,  which  opera- 
tions may  bring  about. 

Recall  our  aphorism  :  In  tuberculosis  the  knife  rarely  cures, 
it  often  aggravates  and  always  mutilates. 

At  the  commencement  of  my  practice,  I  operated  and  re-oper- 
ated  upon  hundreds  of   fistulse  ;  I  obtained,   doubtless,   some 


ii|'i:u.VTlO\    OUGHT    TO    ItK     \I,\\.V\S    ItlMKC  IKD 


:u 


cures,  but  uiany  more  agjiravalions.  So  much  so  thai  f  treat 
llicm  today  by  (he  conservative  metliod  ;  I  operate  no  longer; 
all    llial    1    do  now   as  iiilcrroreiicc,    if  it  may  he   called   a  real 


T-^-ry —  ■  -  ■— 

^^^^^^1 

■r* 

^^^^^ 

■PS-i 

T 

F 

; 

M 

^^^^^^^^^^^^__j^ 

^^kii.^ 

Fig.  igo.  —  Fistula  communicating  with  a  deep,  bony  focus  (Pott's  disease  in  lumbar 
region)  :  the  fistulous  orifice  was  found  within  four  inches  above  the  centre  of  the 
left  iliac  crest;  an  injection  of  very  soft  iodoform  paste  before  the  photograph  was 
taken  shows  the  different  diverticles  of  the  collection.  — T.  Tampon  obstructing  the 
fistulous  orifice.  —  I.  Focus  and  principle  cavity  of  the  abscess  filled  with  iodoform 
liquid.  —  P.  P.  P.  Secondary  pockets.  —  one  of  these  descends,  on  the  right  side, 
down  to  the  internal  iliac  fossa;  one  conceived  that  there  was  very  poor  assurance 
of  perfect  drainage  with  a  sinus  so  anfractuous.  If  fever  appears,  or  if  the  cure 
takes  too  long,  a  counter  opening  will  be  indicated  at  the  lowest  point. 


interference,  is,  in  the  extremely  rare  case  where  I  find  by 
examination  of  the  sinus  a  mobile  sequestrum,  to  extract  it 
—  without  doing  more,  without  touching  the  sinus. 

The  cures  efTected  by  my  conservative  treatment  today  are 
incomparably  more  numerous  and  more  beautiful  than  those 
obtained  by  my  treatment  by  operation  years  ago. 


232  OX    OPERATION    I>"    TLBERCULOUS    FISTULA 

The  question  has  been  settled,  the  only  treatment  of  tuber- 
culous fistula  should  be  conservative. 

You  may  rely  on  our  very  great  personal  experience  of  the 
tAvo  methods. 


Fig.  igi.  —  These  fistula^,  of  three  years'  standing,    proceeding  from  a  tuberculous 
pleurisy  (empyema)  have  been  cured  by  a  single  injection  of  our  naphtol  paste. 

Once  again,  do  not  allow  yourself  to  be  troubled  by  the 
thought  that  there  Avill  be  small  sequestra,  an  objection  which 
will  often  be  made  to  you  by  the  advocates  of  ■'  operation  at 
all  costs  ". 

First,  sequestra  here  are  very  rare.  I  have  said  so,  but 
supposing  they  do  exist,  it  is  in  the  two  following  condi- 
tions : 


IIKKi;    ol'KIUrioN    IS    GENEKAI.LY     IIAUMrl'L 


■a:v6 


EitluM'  {a)  YOii  I'md  llie  sequestrum  already  completely  deta- 
ched, edsil)'  (irccssihle  and  it  is  evident,  as  we  have  said,  that 
you  can  and  (hiliIiI  Io  seize  il  wllli  the  f()rceps,  just  as  you 
\\(inl(l  aii\  loreiiiii  body;  but  be  coiileiiled  with  that;  you  can 
do   it    Y\itiiout    aniesthesia    and    without   causing  ha?morriiage. 


Fig.  192.  —  Fistulffi  proceeding  from  hip  disease;  these  fistulae,  of  eighteen  months' 
standing.  Ijave  been  dried  up  by  sis  injeclions  of  our  paste  in  the  space  of  two 
months. 


Or,  (b)  the  sequestrum  is  not  mobile  or  is  not  easily  accessible; 
well,  abstention,  in  that  case,  would  be  better  than  operation. 

For  sequestra  are  AAorn  aAvay  and  eliminated  by  the  aid 
of  injections,  and  even  spontaneously  in  the  long  run,  nearly 
always. 

In  abstaining,  you  observe  the  prirno  non  nocere.  Whilst 
operation  will  not  be  without  danger. 

a)  For  if  you  have  recourse  to  a  very  extensive  cutting 
interference,   so-called  radical,  you  run  much  risk  of  spreading 


2  34 


0>f    THE    BEST    TREATMENT    OF    TUBERCULOUS    FISTUL/E 


(in  place  of  limiting)  the  region  pertaining  to  the  tuberculosis  ; 
it  will  produce  new  sequestra  and  the  only  result  of  the  ope- 
ration will  be  an  aggravation,  a  mutilation.  The  patient  will 
be  mutilated,  even  when  the  tuberculosis  is   superficial. 


Fig.  193.  —  Symptomatic  crural  fistulic  in  a  case  of  dorso-lumbar  Polt's  disease.  Tiie 
fistulae  which  had  existed  a  year  and  a  half  were  cured  in  four  months  by  our 
paste  injections. 


For  example  :  if  you  curette  a  finger  affected  with  spina 
Tentosa,  to  be  quite  certain  you  have  reached  the  limits  of  the 
disease  you  will  have  to  go  beyond  it  and  cut  into  sound 
tissue ;  you  will  unavoidably  go  too  far,  and  thus  the  patient  will 
■come  away  from  the  operation  more  mutilated  than  if  he  had 
waited    for    the    spontaneous    elimination    of    the   deepest 


Tin;   \  Ml  i:   m    \i!-ti.\  iion,    i-iumdi  mi  u  u'i;i  i  m;   Miniions    :j35 

osseous   debris   present.     Nature,    in    iIh'   cimI.    will    iii;iii,i"-e 
liiiit'^s  iniirli  iiiMiv  ccoi icalJy  than  llic  .sur^c(jii. 


/>)  Abstention,  llicii.  Is  df  iikmc  \aliic  ihaii  siir.i^ical  0|)c- 
ralion.  Thai  i<.  a  paliciil  placed  at  rest,  in  the  ^^ood  air  of 
tlie  connlrx.  and  especially  near  (he  sea.  with  good  general 
Ircalnient  anil  no  dllicr  hjcal 

treatment   than  good  aseptic      | 

dressings,  has  mucii  more 
chance  ol"  seeing  his  lisluhe 
close  than  hy  ojieralion. 
That  is  to  say,  again,  that 
the  country  practitioner  who 
never  operates,  will  cure  a 
greater  numher  than  the 
great  surgeon  who  always 
operates  and  ohstinatelv  re- 
operates.  But  I  am  lea- 
ching you  nothing  :  have 
not  every  one  of  you  seen 
a  great  numher  of  those 
fistula?  cured,  which  had 
never  been  touched  .** 


Fig.  if)^.—  Poll's  fistula  situate  in  tlie  proxi- 
mity of  a  focus.  It  was  a  dorso-luinbar 
Pott's  disease:  ttie  fistulous  orifice  \Yas 
ij  centimetres  witliout  and  to  the  rij:bt  of 
tlie  spinous  apopliysis  of  the  second  lum- 
bar. The  fistula  was  treated  through  an 
opening  in  a  plaster  apparatus;  it  dried 
up  after  five  injections  of  our  paste  in 
about  two  months.  The  cicatrised  fistula 
is  seen  here  through  the  opening  in  the 
plaster  corset  which  the  patient  still  wears. 


c)     Physio-therapeutic 
Methods. 

AA  hat  has  iTOt  l)een  tried, 
since  Bier's  method  '.  the  X 

rays,  sunlight  cures,  violet  rays,  radium,  up  to  sea  bathing  at 
all  our  shores  of  the  Nord  and  of  the  Midi,  and  salt  baths,  either 
mineral  or  thermal,  at  all  the  reputed  stations  :  Salies, 
Kreuznach,    etc.,    etc.      These    medications    are    not    without 


I.  Bier's  metliod,  of  wliicli  I  liave  said  tliat  it  has  no  action  against  the 
bacilli,   may  act  favourably  against  staph\lococcal  or  streptococcal  infection. 


236 


THE   BEST    TREATMENT    OF    FISTUL.E    :    THE    INJECTIONS 


value,  they  may  succeed  in  very  superficial  fistula?,  and  espe- 
cially in  ulcerations  and  tuberculous  sores  on  the  surface, 
acting  by  improving  the  general  condition  of  the  patient, 

I   have   tried  all   these   medications,  which  have  sometimes 


Fig.  I  go.  —  Another  case  of  cured  fistula  in  Pott's  disease.  The  patient,  aged  52, 
had  a  large  abscess  in  Petit's  triangle.  The  abscess  had  been  punctured  ai.a 
injected  already  three  times  ^vhen  the  patient  was  obliged  to  leave  Berck  and  sus- 
pend the  treatment  for  several  Aveeks.  On  his  return,  the  skin  was  of  a  violet 
tint,  almost  black  at  two  places  and  a  few  drops  of  pus  issued  through  orifices  of 
the  calibre  of  a  pin.  It  was  impossible  to  avert  the  opening  which  occurred  in 
about  two  davs  by  the  giving  way  of  two  small  scars  in  the  skin ;  we  recommen- 
ced our  injections:  the  sores  were  closed  again  in  about  four  weeks  and  have 
remained  so.      (This  was  over  six  months  ago.) 


effected  a  cure,  but  infinitely  less  frequently  than  the  medicated 
injections  I  am  about  to  describe. 


d)  The  modifying  injections,  made  wilh  the  liquids  indi- 
cated, and  in  the  manner  described  on  p.  170.  ^\ith  these 
injections   cure   may  be    obtained  almost   always,  even  in   the 


iiii>L\iL:  or    nil.    iui.aimi.nt   iok   each   ca^k  ok   ii-ri  i.a    li.l-j 

osseous   fisliiln-.    providetl    lliev   arc    not    iiirocicd  and  proNidcd 
tliat  one  does  not  neglect  aii\   of  ihe  general  indications  given. 

^^e  may  now  indicate  tlic  Ircatment  olearli  variety  of  sore, 
or  tuberculous  fistula. 


I.  The  Treatment  of  Tuberculous  Sores  and  Ulcerations. 

They  are  cured  Avith  various  topical  remedies,  varxing 
their  use  :  the  application  of  our  jDOANdcr'.  tincture  of  iodine, 
peroxyde  of  zinc,  compresses  soaked  with  iodoformed  creosote 
oil,  camphorated  naphtol  with  glycerine,  permanganate  of 
potash,  the  application  of  ^  igo  plaster  (fresh),  nitrate  of  silver, 
the  thermo-cautery.  the  galvano-cautery,  dressings  of  oxyge- 
nated water  or  naphtalan. 

Physio-therapeutic  treatment.  X  rays,  and  high  fre- 
quency currents  (these  two  may  hardly  ever  be  used  except  by 
specialists),  exposure  of  the  sore  to  sunlight,  proceding  gra- 
dually and  methodically,  sometimes  sea-baths,  salt  baths. 

In  cases  somewhat  refractory,  I  have  made  a  circle  of 
modifying  injections  all  round  the  tuberculous  sore  (injections  of 
creosoted  oil  or  of  naphtol-camphor). 

2.  Treatment  of  Fistulae  in  the  Second  Group. 
(Symptomatic  Fistulae  of  Tuberculosis  of  the  Soft  Tissues.) 

Make  small  injections  of  oil,  creosote  and  iodoform,  or  of 
naphtol-camphor,  but  making  provision  for  keeping  the  liquid 
in  position.  If  the  liquid  is  not  easily  kept  in  position,  use 
our  paste  according  to  the  technique  and  dosage  you  already 
know  (p.  176). 

I.  See  the  formula  nl'oiir  powder,  p.   162. 


238  THE    TREAT ilENT    OF    FISTUL.E.    I\    EACH    CASE 

3.  Treatment  of  Fistulse  of  the  Third  Group. 
(Osseous  Fistulae  with  Short  Sinuses.) 

Make  the  same  injections  and  in  the  same  manner  as  above. 

4.  Treatment  of  deep  Fistulae. 

(Hip    Disease,   Pott's   Disease.) 

a.  If  they  are  not  infected,  if  there  is  no  fever,  no  albu- 
men, make  modifying  injections  as  above. 

6.  If  they  are  infected,  with  evening  fever  resulting  from 
the  retention  of  pus,  try  to  suppress  retention  by  simple  drai- 
nage. If  you  do  not  succeed  thus,  avoid  the  injections.  Avoid 
still  more  carefully  the  temptation  of  extensive  surgical  interfe- 
rences, so-called  radical,  which  have  twenty  times  more  chance 
of  injuring  the  patient  than  of  improving  his  condition.  Confine 
yourself  to  a  treatment,  perhaps  more  modest,  but  incontestably 
better,  which  is:  ensure  the  rest  and  immobilisation  of  the 
affected  part  with  fenestrated  plasters,  asepsis  of  sores  as  perfect 
as  possible,  and  now  and  then  attempt  discreetly,  and  for  a 
short  while,  some  of  the  physiotherapeutic  methods.  In  addi- 
tion, a  good  general  treatment.  The  general  treatment,  so 
important  here,  comprises  life  in  the  open  air,  in  the  country, 
or  better  still  at  the  sea-side;  a  well-directed  dietary,  Avhich 
includes  plenty  of  milk ;  and  thus  you  may  be  able  to  prolong 
the  patient's  life  for  several  years,  sometimes  you  may  cure 
him.  We  have  cured  some  in  this  way,  even  cases  of  extreme 
gravity,  and  Ave  have  witnessed  veritable  resurrections.  One 
must  never  despair. 

But  too  often,  however,  we  remain  powerless,  and  death 
will  be  the  usual  termination  of  these  profound  infections  in 
hip  disease  and  more  especially  in  Pott's  disease.  And  for 
that  reason,  I  can  never  repeat  too  often  the  fundamental 
dogma  of  the  treatment  of  external  tuberculosis  "  Never  open, 
nor  allow  to  open,  the  tubercaloiis  foci. 


CHAPTER  V 


POTT'S   DISEASE 


The  objective  should  he  to  cure  without; 

gibhosity. 
In  order  to  cure,  do  not  open  the  abscess. 
To  cure   without  gibbosity,    make  good 

plaster  corsets. 


A  reminder  of  some  Anatomical  and  Clinical  Points 
indispensable  in  treating  Pott's   Disease. 

Pott's  Disease  is  a  tuberculosis  of  tlie  vertebral  column.  The 
lesion  is  situated  in  the  anterior  part,  in  the  bodies  of  the  verte- 
brae (fig.  196  to  199). 

Five  Cases.  —  First  Case.  Before  a  gibbosity  has  appeared 
(fig.  196).  Like  all  the  Avhite  swellings.  Pott's  Disease  goes  on  for 
some  time,  several  months  and  even  one  or  two  years,  without 
deformity  or  gibbositv  ^  It  mav  remain  unobserved,  but  generally 
it  makes  itself  known  bv  some  radiating  or  local  pains,  intermitting, 
or  by  a  functional  weakness,  caused  bv  reflex  muscular  contractions  : 
defective  walking,  difficultv  in  stooping,  rapid  fatigue,  etc. 

Second  Case  :  Gibbosity  (fig.  197,  198,  199).  Second  period  ol" 
the  disease. 

I.  Pott's  disease  mav  even  never  present  a  rjibboshy,  but  that  is  infinitely- 
rare  in  children,  a  little  less  rare  in  adults. 


24o 


i^^  CASE  :  pott's  disease  without  gibbosity 


But   Ave  rarelv   see  children  at  the  first  period.      Most    often, 
Avhen  they  are  brought  to  us  there  is  already  a  gibbosity.     This  is 


Fi 


^_  ig(5.  —  Pott's  disease  before 
cjibbosily,  a  tubercle  has  appeared 
in  the  centre  of  the  body  of  a 
vertebra  ;  around  this,  a  zone  of 
rarefaction  and  softening  favou- 
ring its  extension. 


Yicr,  ig8. —  The  gibbosity  accentualed. 
The  tuberculosis  has  progressed 
from  one  vertebra  to  the  others 
above  and  belo^v,  ^vhich  are 
beginning  to   soften  and  to  sink. 


X-  197.  — •  Beijinninj  of  the  gib- 
bosity. The  tubercle  has  pro- 
gressed, perforated  the  anterior 
wall  of  the  body  and  produced  an 
abscess  ;  the  vertebral  body 
collapses,  hence  the  gibbosity  is 
produced  behind. 


pio-.  T99.  - —  Tlie  gibbosity  has  pro- 
(iressed  at  the  same  time  as  the 
anterior  lesion.  Of  the  first  di- 
seased vertebra  only  the  posterior 
arc  and  an  insignificant  part  of 
the  body  remain .  What  is  left  of 
it  is  by  degrees  pushed  backward 
by  pressure  of  neighbouring  ver- 
tebrae, as  is  the  stone  of  a  cherry 
when  you  squeeze  the  fruit  bet- 
ween your  fingers. 


produced  :  a)  by  flexion  of  the  spine;  h)  by  the  collapsing  ot  one  or 
tyvo  bodies  of  vertebrae,  softened  by  the  ravages  of  tuberculosis  -, 
c)  sometimes  bv  sub-luxation  of  the  two  spinal  segments. 


'.>^"    CASK 


l'<  I  I  I    ^     1)1^1,  \-|.     \\  II  II    (.ijtiwxilY 


2^1 


At  the  outset,   the   gibbosity  is    ancfiilar,    in  the    middle 
line,    and  painful  on  pressure. 

Tlio  liy^iiics  i()7.  i(j8  and  i(j(j  sliow 
how  a  ^ibhosilv  is  producofl.  It  pro- 
l:i('sscs:  lalcr  on  appear  adaptations, 
llial  is,  s(>contlar\  dd'onuilit's  ol'  olhcr 
|)ar(s  oT  the  spine,  and  even  of  the 
Ihoiax.    oC  the   pelvis,   of  the   head,   all 


Fig.  200.  —  Las'  sUiie  of  a 
gibbf.s'ty.  The  patient 
has  become  a  liunch-back 
(whe  I  he  has  not  been 
treate  1  or  not  well  trea- 
ted.) 


:,.  ^', ,  fe 


Fig.  201.  —  Abscess  and  tlstula  iii  I'olLs  disease. 
Abscess  by  gravitation  in  tlie  iliac  fossa.  On 
the  left,  an  abscess  has  travelled  down  to  the 
thigh,  passing  in  the  shape  of  a  wallet,  beneath 
the  crural  arch.  F.  Orifice  of  a  fistula  above  the 
crural  arch. 


deformities  which  contribute  to  giving  to  the  humps  tlicir  character- 


Fig.   ao2  to  20'i.  —  The  three  principal  causes  of  paraplc-i;iu.  Compression  of  thecord. 

i"  by  a  projection  of  hone.  2°''  by  an  abscess.  S"'  bv  pachymeningitis. 

istic  outline  I'v.  fig.  200). 

Cvi.OT.   —  Inilispcnsable  orthopedics.  iC 


242    3'"'   CASE   ;    pott's   disease   with  abscess.  4™  CASE   :   FISTULA 


The  o-ibbosity  is  generally  less  in  Pott's  disease  of  the  cervical 
and  lumbar  regions  than  in  the  dorsal  region. 

Third  Case  :  Abscess.  -  Fourth  Case  :   Fistulae  (lig._20i).  — 
The  bacillary  focus  does  not  remain  localised  in  the  bodies  of  the 


Fig.  2o5. Pott'sdisease  from  ils  commen-  Fig.  206.  —  Gibbosity  at  the  fifth 

cement.      Slight  projeaion  of  the  spinal  dorsal  (at  the  beginning), 

apophysis  of  the  sixth  dorsal  vertebra. 

vertebrae  :  it  may  invade  the  neighbouring  soft  parts  and  send  pro- 
longations of  fungous  granulations  more  or  less  far  towards  the 
neck,  the  thorax,  the  back,  but  especially  to^vards  the  lowest  parts  : 
internal  iliac  fossa,  root  of  the  thigh :  —  and  the  softening  of_  these 
granulations  constitutes  the  abscess  by  gravitation  of  Pott's  disease. 


.V"   CASE    :    poir's   DisKAsi;    wim    i'vit\i.\sis 


2',.S 


egion, 
ilinosl 


Those  ahstcsscs,  rare  in  I'oll's  disease  ol'  Ihc  upper  dorsal  n 
are  more  rrcciueiil  in  Poll's  disease  of  llic  cervical  rcion,  and  .1 
constanllv  present  in  lumbar  and  doiso-lumbar. 

'n.ev  mav  -n  to  tlic  Icn-ll.  of  ulceration  and  breaking  dow  n  o. 
\\u'  -kill,  wli.MK'c  (lie  lorniation  o{'  Jislnhc  which  are  so  easMiy  inlec- 
I.hI  :  Ihis  inleclion  is  very  grave,  leading  I..  |ho  degeneralion  of  the 


F.g.  207.  —  Ordinary  type;  median  and  aogular  projection  ;  the  attitude   in  cervical 

Pott's  disease. 

liver  and  kidneys  and  is  very  often  fatal.  —  Fistula  is  the  greatest 

danger  which  menaces  the  life  of  these  patients. 

Fifth  Case  :  Paralysis  dig.  202,  2o3,  2o4).  —  The  fungous 
prolongations  may  be  directed  also  towards  the  spinal  cord  The 
compression  produced  by  the  abscess  (fig.  2o3)  will  then  give  rise  to 
a  paralysis  more  or  less  complete.  The  paralysis  mav  be  due  also  lo 
a  projection  ol  displaced  bone  (fig.  202)  or  to  a  propagation  of  the 
tuberculosis  lo  the  meninges  and  cord  (fig.  2o4)  or  to  some  trouble 
ol  the  vascular  or  lymphatic  circulation  in  them. 


244    PROG>OSIS    ACCORDl>G    TO    WHETHER    IT    IS    TREATED    OR    NOT 

As  is  the  case  Avitli  gibbosity,  paralysis  is  more  frequent  in  Pott's 
disease  of  the  dorsal  and  cervico-dorsal  regions  than  in  Pott's 
disease  of  the  t^vo  extremities  of  the  spinal  column.  It  is  the 
reverse  with  abscesses. 

Of  the  three  great  symptoms,  gibbosity,  abscess  by  gravitation, 
paralysis,    the    first    (gibbosity)   is   nearly    ahvays    present;    abscess 


Fis.  oos. 


Ordinarv  type  ;  median  and  angular   gibbosity. 


exists  in  about  half  of  the  cases,  and  paralysis  only  once  in  5  or',  6. 
—  The  three  may  exist  together,  but  this  is  very  rare.     Generally 


Fig.  209.  —  Looking  for  pain.  Succussion ;  one  seizes  between  the  thumb  and  fore- 
finger, the  spinous  process  of  the  projecting  vertebra,  pressing  upon  it  with  short 
and  quick  lateral  movements. 

Avhen  an  abscess  is  apparent,  there  is  no  paralysis,  and  vice  versa; 
on  the  other  hand,  gibbosity  generally  co-exists  with  abscess  or 
with  paralysis. 

Prognosis. 

This  differs  entirely  accordinij;  as  the  disease  is  treated  or  not. 

A.  If  the  disease  is  not  well  treated  : 

a.  Tlie  gibbosity  will  develop  more  and  more,  and  the  patient,  if 
he  survive,  will  remain  hunch-backed. 

b.  Abscesses  are  more  frequent,  more  bulky  :  but  especially  do 
they  produce  fistulte.  And  fistulous  Pott's  disease  nearly  alwavs 
ends  with  the  death  of  the  patient,  sooner  or  later. 

c.  Paralysis  is  equally  more  frequent  and  is  often  fatal. 

B.  On  the  other  hand,  if  the  Pott's  disease  is  being  well  trea- 
ted : 

The  gibbosity  if  recent  will  be  not  only  arrested  in  it's  pro- 
gress, but  effaced. 


1)1  It  \  I  KIN   (ii-    riii:    iiisi.\si: 


■>.lxb 


Ahscessex  will  ho  loss  rro([iicn(   :   ahovo  ail  tilings.  Iliov  will  cure 
because  tliev  will  nol  be  opened  or  allowed  to  open. 


Fig.  2  10.  —  Dorso-lumbar  Pott's  disease;  typical  attitude. 

Paralysis   uill  be  verv   rare   and,  if  it  supervene,  will  be  cured 
19  times  out  of  20. 

Duration  of  the  Disease. 


The  duration  depends  especially  upon  the  treatment  carried  out, 
and  slightly  upon  the  particular  case,  because  the  tuberculosis  maybe 
more  or  less  virulent.     On  an  average,  it  is  necessary  to  reckon  irora 


46 


POTT  S    DISEASE. 


DIAGNOSIS 


three  to  four  years,  sometimes  less,  often  more.  In  the  case  of 
abscess  well  treated,  the  duration  of  Pott's  disease,  instead  of 
being  prolonged  on  account  of  the  abscess,  is  notablv  shortened. 


Dias:nosis. 


The  ordinary  case.     A  child  is  brought   to   consult   you   about  a 
gibbosity-      Three  times  out  of  four  one  has  only  to  look  at  it  to  see 


Fig.    211,    a  12,    : 

i"  stage.  The  patient  flexes 
his  knees  instead  ol 
freely  flexing  the  trunk. 
He  uses  his  right  arm 
to  balance  liimself  in 
order  to  preserve  his 
equilibrium. 


i3.   —    The   patient   is    asked   to    pick  up    an 

object  placed  on  the  floor. 

2°*  stage.     The  left  knee  is 

in      contact     -with     the 

ground,    the    left    hand 

seizes  the  object. 


3"*  stage.  The  patient  raises 
himself  by  means  of  his 
right  hand,  which  takes 
a  point  on  the  thigh  as 
a  fulcrum. 


that  it  is  due  to  Pott's  disease.  Indeed,  if  the  parents  bring  the 
child  to  you,  it  is  because  they  are  concerned  at  the  appearance  of  a 
prominence  in  the  middle  line  of  the  back,  and  they  want  to  knOAV 
what  it  is. 


i)iA(i.\u.si.>    WHEN    JiiMu:   Is    \    (;iiiii(i>ri  \ 


■yA- 


How     one    recognises     the      gibbosity     of     Pott's     disease. 


Fig.    2i\.   —   Esaminini;-    the   mobility;    healthy    subject.      In    hyper-extension,    the 
entire  spinal  column  participates  in  the  movement  and  forms  a  regular  curve. 


Fig.  3i5.  —  In  the  aEfected  subject,  the  diseased  segment  (2''  presents  rigidity  and  the 
spinal  column  forms  a  broken  line,  1,2,   i. 


(Gg.   197  to  209).     We  have  already   said   it   ;   It   is  median  (over 


248 


POTT  S    DISEASE. 


DIAGNOSIS 


one  or  two  spinous  apophvses  i,  2"'.  it  is  angular,  '6''.   it  is  painful 
on    pressure,  and   especially    on    lateral    succussion    (fig.    209J. 


Fiff.  216.  —  Lumbar  Pott's  disease;  there  is  no  o^ibbosily  strictly  speaking,  but  tbe 
physiological  lordosis  has  disappeared,  that  is  sufficient.  —  Here  the  diagnosis 
was  confirmed  a  month  later  by  the  appearance  of  an  abscess  in  the  left  iliac  lossa. 

Moreover,  the  attitude  is  "  stiff  "  (fig.  200  and  2191  and  there  is 
rigidity  of  the  spinal  column.  —  The  patient  ^^  alks  all  in  a  block, 
without    anv    tlexihilitv  1  fie.   2101.      In    order  to    bend    down    and 


1)1A(.\I>-I--     WIIKN      Ml    (.IIilt(lMI>      IS     rUliSIiNT 


■2'\() 


nick  up  ;iri  olijcci  on  llu"  i;i(iiind.  lie  does  not  bend  llic  trunk 
Ircelx  :  Ik-  flexes  the  legs  and  kneels  down  rallier  llian  stoops 
(fii^.  21  r ,  aia,  :mo  ).  ir  one  raises  up  llic  t'vo  limbs  and  llie  pelvis 
of  llie  sul)jccl  laid  on  his  belly,  llie  l)ack  does  not  bend  in  llic 
cuslomarv  \va\  :  it  resists  like  a 
board  (tig.  ui/j.  :u5). 

Finallv,  the  general  condition 
is  olten  below  par.  and  the  ordi- 
nar\  antecedcnl-;  ol  luberculosis 
mav  be  found. 

Less  frequent  case.  Ao  yibbo- 
sity  has  appeared.  —  Once  out  of 
four  times  \ou  are  consulted  onlv 
for  functional  Irouliles :  nothing 
is  mentioned  as  being  wrong 
with  the  back.  It  is  for  you  to 
think  of  it  and  examine  the  spine. 

a.      W  hen  a  child  is  brought 

o 

to  >ou  carrying  himself  badlv 
(fig.  2IO),  is  quickly  fatigued, 
complains  of  a  stitch  in  the  side, 
or  girdle  pains,  or  pains  int  he 
limbs,  diurnal  or  nocturnal,  ne- 
ver neglect  to  completely  exa- 
mine the  patient  perfectly  nude, 
and.  to  carefully  inspect  the  back 
and  the  lower  limbs. 

If  you  find  a   gibbosity,  the 

diasrnosis  is  easv. 

•  •  •  1 

Failing  that,  if  you  find  pain  on  succussion,  stiffness  in  wal- 
king, difficulty  in  stooping,  these  will  suffice  to  make  a  diagnosis 
of  Pott's  disease. 

h.  Sometimes  the  patient  is  brought  to  you  only  for  an  abs- 
cess —  cold  pararaclddian  —  (in  the  neck,  the  back,  the  thigh,  or 
the  internal  iliac  fossaj.  Think  of  Pott's  disease  and  examine  the 
back.  Bilateral  symmetrical  abscess  is  an  indication  of  Pott's 
disease  99  times  out  of  100  :  but  unilateral  abscess  should  also  make 
\ou  think  of  it. 

c.  More  rarelv,  it  is  for  paralysis  that  you  are  consulted. 
Think  here  again  of  possible  Pott's  disease,  and  look  for  the  diffe- 
rent signs  whicb  have  been  uiven  \ou  about  that. 


l-'i'^  217.  —  Itare  type  :  p<eu(lo-scijliotic 
form.  An  iliac  aloscess  sliortty  con- 
firms tlie  diagnosis  atready  made  of 
Pott's  disease. 


25o  DIFFERENTIAL    DIAGNOSIS    OF    POTT  S    DISEASE 

Differential  Diagnosis  and  Causes  of  Error. 

With  Aviial  can  it  be  conluscd  ? 

a.     The  gibbosity.  —  If  tins  is  very  sliglit,   and  situated  at 


Fi",    218.  —  Another  rare   type;  median  gibbosity,  but  no  angularity, 
The  tuberculous  round  back. 

the  seventh  cervical  vertebra,    do  not  forget  the  prominence  nor- 


Fig.  219.  —  A  rare  type,  of  the  same  kind  as  in  fig.  218  ;  Pott's  disease  of  the 
kyphotic  form ;  median  gibbosity,  but  not  angular. 

mally  made^by  the  seventh  vertebra,  called,  for  this  reason,  the 


i)iA(;\()Sis    Willi    si:( ii.iosis  ubi 

lifiiiitincns.  In  llio  iKunial  CDiulilioii,  llioiv  is  no  [)aiii,  no 
slilTncss,  etc. 

Il  is  llie  same  willi  llio  tenth  dorsal,  -wliicli  often  presents  a 
slight  (normal)  prominence  ol    a  lew  milliniclrcs. 

On  (Iio  conlrarv.  the  lumbar  and  cervical  regions  are  normally 


Fig.  220.  —  Cervical  Pott's  disease;  —  lel't  torticollis  and  Kstula  on  the  right,  in  the- 
sub-clavicular  hollow.  He  came  to  Berck  Avith  a  diagnosis  of  suppurative  cervical 
adenitis,  which  had  been  opened.  We  recognised  Pott's  disease  by  pain  on  pres- 
sure over  the  third  cervical  vertebra,  stiffness  of  the  neck,  and  by  a  retro-pharyn- 
geal  abscess  (see  fig.  221),  communicating  with  the  fistula. 

concave.  One  ought,  then,  when  they  appear  flat  (fig.  2 16),' to 
ihink  at  once  of  Pott's  disease,  and  look  for  the  other  signs  :  pain, 
stillness,  etc. 

Scoliosis  sometimes  presents  a  median  knob,  but  this  is  nothing 
compared  to  the  two  lateral  curvatures  in  the  opposite  direction 
■which  are  below  this  median  knob. 


202 


DIAGNOSIS   ^VITH    THE    ROUND    XON-TUBERCULOLS   BACK 


It   Avill  be  well,   ho^vever,   to  reserve  our  diagnosis,  IT  at  the 
same  time  there  is  a  lateral  curve,  and  marked  pain  over  a  spinal 

apophysis;  because  one  has  seen  Pott's  disease  assuming  the  scoliotic 
form  (fig.  217). 

The  round  back  is  a  non-tuberculous   deformity   (v.   chap.  ix). 


-^^  J- 


-iTc-^^y 


Fig.   221.  —  The  child  in  fig.  i-Ii;  abscess  pushing  up  the  right  side  ol'  the  pharynx. 
Uvula  puslied  to  the  left,  right  edge  of  soft  palate  pushed  dov\n. 

Nevertheless,  Pott's  disease  may  sometimes  present,  instead  of  an 
acute  gibbosity,  a  regular  curve  of  several  vertebrae  (fig.  218,  219), 
aground  back,  Avhich  is  then  painful  and  stiff,  ^vith  a  poor  general 
condition.  These  characteristics  ought  to  make  one  think  of 
Pott's  disease,  or  at  least  to  make  one  reserve  the  diagnosis  ^ 


I.  For  thediagnosis  of  rachitic  kyphosis,  v.  p.  634- 


1>OTt's    DlSli.VSE.    DI.VGNOSIS    IN    Till;    CASK    OF    ABSCESS     2J.i 

But  ho  roassnrod,  hocouse  il  is  i-;ii-el\  llial   I'ult's  disease  appears 
under  llic  loini  nl  lalciid  dfloiinllv  or  of  romid  back. 


Fio.  2  22.  —  Touch  often  allo\YS  one  to  distinguish  an  abscess  by  rjravilalion  in  the 
neck  from  an  idiopathic  or  glandular  abscess.  If  it  is  a  pharyngeal  abscess  of 
vertebral  origin ;  a  hnger  laid  on  the  posterior  border  of  the  sternomastoid  and 
exercising  light  but  jerky  pressure  over  the  deep  tissues,  will  convey  the  impres- 
sion of  fluid  to  the  index  finger  introduced  into  the  pharynx,  on  the  left.  This 
sensation  would  be  absent  in  the  case  of  glandular  abscess  (c)  on  the  right. 


Fig  233.  —  The  method  of  palpating  the  internal  iliac  fossa  in  looking  for  an 
abscess  ;  the  pulps  of  the  fingers  are  firmly  pressed  into  the  abdominal  wall,  pushing 
aside  the  intestinal  mass. 


Gibbosity  following  accident  :  the  diagnosis  is  bv  the  history 


254        POTTS    DISEASE.    D1AG->'0SIS    IN   THE    CASE   OF     ABSCESS 

of  very  grave  injury,  by  the  sudden  appearance  of  the  deformity, 
with  general  medullary  symptoms,  etc.  ^ 

6.  Abscess.  —  Causes  of  error  in  diagnosis. 

If  there  is  behind  the  pharynx  a  cold  abscess,  one  will  always 
think  of  Pott's  disease.  One  will  examine  and  palpate  the  cor- 
responding spinal  apophyses ;  one  Avill  look  for  antecedents,  tor- 
ticollis, intermittent  or  chronic,  radiating  pains  about  the  neck,  the 
arms,  etc.,  in   such  a  way  as  not  to  mistake  a  Pott's  disease  for 


2  2  /| .     


Palpation   of  the  iliac    I'ossa ;    ihe  hand,    in   pushing  aside  ihe   intestinal 
mass,  comes  in  contact  with  the  wall  of  the  abscess. 


a  simple  idiopathic  retro- pharyngeal  adenitis.     Cervical  adenitis 

is  distinguished  from  abscess  by  gravitation  (of  the  neck)  by  the 
same  signs  (fig.  220  to  222).  When  an  abscess  is  situated  in  the 
right  iliac  fossa  (lig,  228  and  22Z1)  take  care  not  to  confuse  this 
Avith  a  cold  appendix  abscess,  an  error  which  I  have  seen  committed. 
One  Avill  distinguish  it  also  from  an  encvsted  collection  of 
peritoneal  tuberculoses,  from  a  simple  glandular  abscess,  and 
especially  from  an  incomplete  hernia,  an  unfortunate  mistake  I 
have  seen  made  (v.  chap.  xix). 

I .  Syphilitic  gibbosities  are  rare ;  they  are  rather  of  a  mixed  form,  a 
«  scrofulate  de  verole  »,  v.  chap.  XXI. 

The  diagnosiswith  spondylitis  deformans  and  other  ankylosing  arthrites 
of  the  spine,  by  the  existence  of  a  large  curvature,  of  generalised  ankvlosis 
of  the  spine,  frequently  stiffness  of  the  joints  at  the  root  of  the  limbs,  etc. 


POTT  S   Ml- 1.  \si: 


i>i\(.\ii-i-   i\    I  in:  cAsi;   <ji'   l■\lt\l.^sls    a;);) 


lliTc  Mu.iiii.    the    diagnosis   may  be    made   by  examination  of 
the  back,   wliicli  ono  sIkhiIiI  hcvcm-  neglect  in  siicli  cases. 
c.      Paralysis  ol'  I'oH's  l)is('as<'. 
iliis  inaN    he  coiilused   somcliiiies    willi    myelitis,    syphilitic  or 


Fig.  225.  —  A  child   ^lie«ing  the  diagnosis  of  rigid    hip  disease.     He    had  a  right 
''iliac  abscess  Avithdorso-lumbar  Pott's'disease  at  the  beginning  (without  hip  disease). 

alcoholic,  and  sometimes  even  Avith  infantile  paralysis,  or  tlie 
paralysis  of  cerebro-spinal  meningitis.  \o\\  avIU  avoid  tins 
conlusion  bv  examination  of  the  back.  analNsis  of  the  other  signs  . 
and  bv  the  liistorv,  different  in  each  diverse  maladx. 

I.  In  the  paralysis  of  Pott's  disease,  the  rellexes  are  exaggerated  from  the 
l)eginning  (ahvays  or  nearly  ahvays).  Later,  spasms  and  contractions,  trou- 
bles of  sensation,   of  the  sphincters,  and  trophic  lesions  (bed-sores),  etc. 


2  56  POTT  S    DISEASE.    —   TREATMENT 

Diagnosis  of  Pott's  Disease  with    some  other  Maladies. 

1.  With  Hip  Disease.  —  AA  hen  a  child  comes  to  you  for  func- 
tional trouhles  only,  that  is,  a  defective  attitude  (fig.  235).  or  a 
haltinf  "-ait,  it  is  necessary  to  examine  successive! v  the  back  and  the 
hip,  (even  the  knee),  in  order  to  discover  if  limitation  of  move- 
ments and  pain  on  pressure  over  the  bones,  etc.,  etc.,  isto  be  found 
in  the  hip  (hip  disease),  or  in  the  spine  (Pott's  disease)  ^ . 

2.  With  vertebral  Rheumatism.  —  If  the  rheumatism  is  very 
chronic,  distrust  it !  How  many  cases  of  Pott's  disease  have  been 
decorated  with  the  name  of  Rheumatism  (or  of  Sciatica)  until, 
sooner  or  later,  a  gibbosifv  or  an  abscess  becomes  conspicuous  to  the 
eves  of  the  practitioner  or  of  the  patient's  friends. 


THE  TREATMENT  OF  POTT'S  DISEASE  '- 

We  are  going  to    describe  :  I.    What  ought    to   be  done ; 
2.  How  it  must  be  dons. 

P'  Part.  —  WHAT  OUGHT  TO  BE  DONE. 

This  depend  upon  the  case.  —  Five  Gases;  i"  no  gibbo- 
sity, no  abscess,  no  paralysis;  a""^  gibbosity;  3"'  abscess; 
4*''  fistula  ;  5*''  paralysis. 

Isi  CvsE.     POTT'S  DISEASE  WITHOUT  GIBBOSITY 
It  may"  happen,  in  patients  who  have  been  very  well  looked 
after,  that    they   come   to  you   before   the    appearance    of  any 
gibbosity.      It  is  rare. 

A.  Therapeutic  indications.  —  To  favour  the  cure  of 
the  tuberculous  focus  and  to  prevent  the  gibbosity  occuring. 

B.  The  Treatment  comprises  two  things  ^ 

1.  Hip  disease  and  Pott's  disease  may  co-exist. 

2.  A\  e  are  onlv  dealing  here  Avitli  local  treatment  —  liecause  we  have 
nothing  to  teach  practitioners  on  general  anti-tuberculous  treatment 
indispensable  for  all  those  patients,  namely,  good  hygiene,  over-feeding, 
medical  treatment,  and  especially  open  air  treatment  (sucli  as  our  jjatients  at 
Berck  enjoy,  out  of  doors  from  morning  until  evening  and  in  all 
weathers). 

3.  Tliese  are  evidently  applicable  to  all  cases  of  Potts  disease,  during  the 
period  of  activity  of  the  disease. 


NECESSITY   OF    THE    PL  VSTEU    CORSET  SOy 

I.      Rest  in  the  recumbent  position. 
II.     A  Plaster  apparatus. 

1.  Rest. — Place  ihe  patieal  al  rol  in  llio  iccuiiihcnl  posi- 
tion, for  one  and  a  half  or  two  years. 

2.  The  Pi.a-ti:h  um-arvtus. — \ou  slioulJ  apply  lliis  at  the 
beginning,  during  the  period  of  rest,  and  the  patient  sliould 
continue  to  wear  a  corset  after  getting  on  to  his  feel,  for  two 
or  three  years  longer,  at  a  minimum,  which  make,  in  all, 
from  four  to  five  vears ;  in  a  word,  he  will  not  leave  it  off 
until  the  welding  of  the  vertebrte  is  accomplislied;  in  the  same 
way.  in  a  fracture,  one  keeps  to  the  plaster  until  after  the  for- 
mation of  a  solid  callus. 

Necessity  of  the  Plaster  apparatus.  —  ?vo  one  seriously 
disputes  the  necessity  of  rest  in  the  recumbent  position  during 
the  whole  period  of  activity  of  Pott's  disease:  but  it  is  not  so 
with  regard  to  plaster  apparatus. 

Why  not  rest  only?  they  say.  Or  a  Bonnet's  splint,  or 
the  "  cadre  ""  with  or  without  extension? 

AVhy?...  Simply  because  all  these  other  treatments  are  not  to 
be  depended  upon  and  are  insufficient.  They  do  not  give  good 
results,  especially  with  children. 

Here  is,  as  to  simple  rest,  the  opinion  of  Lannelongue  : 
"  One  sees  in  Pott's  disease  gibbosity  produced  and  aggravated 
in  spite  of  horizontal  decubitus.  I  could  quote  a  respectable 
number  of  clinical  instances  where  gibbosity  has  continued  to 
progress  in  spite  of  decubitus  very  strict  and  of  long  duration. 

Passing  on  to  the  value  of  splinfs  :  ••  I  have  seen  at  Berck- 
sur-Mer  ",  says  another  surgeon.  •■  gibbosities  beginning  and 
augmenting  in  splints  ".  And  Lannelongue  on  the  same  topic 
says,  "  Oftentimes,  when  llie  child  is  taken  out  of  the  splint, 
he  is  deformed  ". 

These  quotations  exempt  me  from  bringing  forward  personal 
observations  upon  numerous  patients  I  have  seen,  treated  else- 
where in  this  way,  in  Avliom  were  produced  gibbosities  more 
or  less  bulky. 

Calot.  —  Indispensable  orthopedics.  17 


258  pott's   disease.     TREATMENT    OF     THE   GIBBOSITY 

Moreover,  that  Avould  astonish  only  those  who  have  for- 
gotten that  every  case  of  Pott's  disease  is  a  fracture  (patho- 
logical) of  the  spine,  already  produced  or  very  imminent,  with 
a  very  marked  tendency  to  the  overlapping  of  the  fragments. 

It  is  necessary  to  prevent  the  displacement  of  the  two 
fragments. 

It  is  easy  to  understand  that  rest  alone  is  not  sufficient 
for  this.  Success  can  only  be  obtained  with  certainty  by 
the  use  of  a  large  plaster,  which  will  support  very  exactly 
the  two  segments  of  the  spine, 

Do  not,  then,  hesitate  to  apply  it  immediately.  Hesitation 
is  so  much  the  less  permissible  seeing  that  the  treatment  by 
plaster  is  not  only  by  far  the  most  efficacious,  but  is,  all  things 
considered,  the  most  simple  and  most  practicable  for  every- 
body :  parents,  patients  and  doctors.  The  other  treatments  : 
splints,  extension  frames,  special  beds,  plastered  beds,  etc., 
corsets  made  of  duck,  with  rest  on  a  board,  in  spite  of  their 
apparent  simplicity,  are,  when  one  reckons  up  everything, 
much  more  complicated,  more  difficult  to  apply  and  look 
after,  and  much  less  comfortable  for  children. 

2"  CASE.  —  POTT'S   DISEASE  WITH  GIBBOSITY 
(much  more  frequent) 

A.  —  Indications  for  Local  Treatment. 

I.  To  arrest  the  growth  of  the  gibbosity.  II.  Correc- 
ting it  if  possible. 

Is  this  correction  logical?     Yes. 

It  has  been  disputed.  It  has  been  vehemently  denied. 
But  we  have  today  the  clinical  and  radiographic  proof  of 
it's  correctness'.      It  will  be  sufficient  to  cast  your  eyes  on  the 

I.  See,  in  La  Clinique  of  July  20th,  1906;  Pourquoi  Von  peat  et  Von  doit 
redresser  les  maux  de  Pott,  par  F.  Calot.  Do  not  lose  time  ;  take  care  not  to 
allow  a  gibbosity  to  increase.  At  this  moment  there  is  scarcely  more  than 
half  a  vertebra  ravaged  by  tuber cvilosis.  Later,  after  one  or  several  years, 
when  3,  4  or  5  vertebral  bodies  have   been  destroyed,  you  will  not  be  able 


AVIIY   you    CAN   AND    OUGHT   TO    UEDRESS 


259 


liguios   lolluwiny  lor  \ou  lo  be  convinced.      (Fig.   006  to  :^'|i.) 

They  demonstrate  that  the  dorsal  gibbosity  has  been  effaced 

at  the  same  time  that  the  spine  has  been  welded  in  front. 


Fig.  226.  —  Abel  L.,  rue  des  Recollets,  Valenciennes.  There  was  a  gibbosity  on  his 
arrival  at  Berck  at  the  age  of  four  years  in  1898  (see  fig.  227  and  2'28  shewing  the 
child  straightened). 

If  the  thing-  has   been    possible    for   certain    bulky    gibbo- 
sities, Avith  all    the  more  reason   will  it  be  possible  in  small 

to  do  much ;  the  treatment  will  then  have  to  be  handed  over  to  a  specialist, 
who  will  not  be  able,  at  this  stage,  to  obtain  a  perfect  cure. 


i 


pi„.    227.  —  The  same  redressed  —  8  years  afterNvards,  in  profile.     The  slight  promi- 
^nence  is  produced  by  the  scapulae  and  not  by  the  vertebral   column  (v.  fig.   226 
and  228). 


Fig.  22S.  —  The  same  ^see  fig.  22G  and  227)  view  of  the  back    in^'igoC) 
8  years  after  redressment . 


262 


YOU    REDRESS    BY   A   SIMPLE   AND   HARMLESS   METHOD 


or  medium    gibbosities,  the    only  ones   you   will  have  to 
treat  in  your  practice  (Fig.  287  to  24o). 

But  should  and  could  a  practitioner,  not  being  a  specia- 
list, undertake  the  correction 

of  a  case  of  even  slight  gibbo- 
sity? Yes,  on  the  same  grounds 
that  he  could  a  correction  of 
hip  disease,  or  of  white  swelling 
of  the  knee ;  for  a  spine  can  be 
redressed  as  easily,  if  not  more 
easily,  than  a  hip  or  a  knee, 
and  withoui  a  shadoiu  of  danger. 
—  Indeed,  let  us  say  it  now, 
every  thing  is  reduced  to  the 
application  of  a  large  plaster 
in  the  upright  position  (suppor- 
ted and  not  suspended;  then 
there  is  no  traumatism)  and  to 
the  making  afterwards  an  ope- 
ningin  the  plaster  through  Avhich 
one  can  make  direct  pressure 
upon  the  projecting  vertebrae, 
cotton  wool  pressure,  at  once 
inoffensive  and  gentle,  but  at 
the  same    time    energetic    and 


Pig.   229.    —  The  patient  in  fig.  226  and 

228.  —  Outline  of  radiogram  by  efficaciouS. 
M.  Infroit,  where  one  sees  ;  ist,  the  ver- 
tebral column  is  continuous  in  front,  B  ; 
2nd,  nevertheless  the  line  of  the  back 
is  straight;  the  gibbosity  has  disappea- 
red, A. 


Seeing  that  you  are  able  to 
do  it,  you  ought  to  correct,  if 
only  to  prevent  a  greater  evil  — 
for  one  is  obliged  to  correct, 

at  least  a  little,  to  make  sure  of  arresting  the  development 

of  the  gibbosity  already  in  existence. 


B.  —  The  treatment  to  he  carried  out'm  case  2  (the  most 
frequent) ,   We  have  just  mentioned  it :  a  plaster,  with  a  dorsal  ope  - 


MECIIAMSM    Ol'    REDRESSMENT    OF    A  GIBBOSITY 


263 


ning,  permits  one  to  obtain  nol  onl  v  retention,  but  also  correction. 

If  the  necessity  of  a  plaster  corset  may  perlia[)s,  be  debated 

in   Pott's  disease  ^\illlOut  gibbosity,    there   is  no    discussion 

possible  in  the  presence  of  a  gibbosity  already  in  existence. 

^^illl    all    the   (tlher    treatnicnl'S,    one    does    not    elTcct    im- 


Fig.  23o.  Fig.  23i.  Fig.  232. 

The  mechanism  of  redressing  a  gibbosity  in  a  case  where  at  the  "anterior  part  the 
thickness  of  one  vertebral  body  is  lost.  —  From  a  ra^liograph. 
Fig.   23o.  —  Before  re:lressment. 
Fig.  281.  — Here  are  the  modifications  which  the  redressment  will  produce.      The  two 
aHected   vertebrae    separate   in  front,  no   longer  touch   one    another  except  by   the 
posterior  parts  of  their  bodies ;  their  articular  apophyses  come  near  each  other ;  all 
the  intervertebral  dises  are  enlarged  in  front.      But  if  one  elTeoted  the  redressment 
progressively  over  several  months,  the  separation,  produced  without  traumatism  or 
destruction,  will  be  filled  in  little  by  little. 
Fig.  282.  —  Four   years   later  redressment  is  accomplished.     The  new  static  condi- 
tions  obtained   have  the    following  effect ;    ist.,  the    compressed  posterior  parts  of 
the  vertebral  bodies  become  atrophied  and  sink  ;  the  two  articular  apophyses  be- 
come more    and    more    imbricated;    2nd.,    all    the   vertebral  bodies    are   pushed 
forward  where  they  are  submitted  to  less  compression ;  this  allows  them  to  develop 
more  at  this  point  (in  front    than  in  their  posterior  parts. 

mediate  pressure  on  tbe  displaced  vertebrae,  and  it  is  quite 
evident  tliat  the  over-riding,  already  present,  of  two  spinal 
segments  may  increase,  and  that  it  will  increase  little  or 
much.  Simple  extension  by  the  feet  and  the  head  will  not 
escape  from  this  reproach  any  more  than  the  other  methods; 
extension    is   too    irregular,    too   difficult  to  carry  out,  and 


264         pott's    disease.     REDRESSMENT    OF    THE    GIBBOSITY 

particularly  too  indirect  to  have  any  real  practical  value.  I 
said  too  indirect ;  indeed,  Avhen  a  gibbosity  of  the  tenth  dorsal 
vertebra  exists,  for  example,  supported  by  sclerosed  or  osteo- 


Fig.   233.  —  ^tay  0.,  London.  Gibliosity  dating  four  years. 

fibrous  adhesions,  an  extension  of  several  kilogrammes  made  to 
the  feet  or  the  head  will  have  perhaps  the  effect  of  stretching 
the  two  extremities,  but  it  will  certainly  not  act  in  pulling  into 
line  the  tenth  dorsal  vertebra,  which  will  continue,  on  the 
contrary,  to  be  displaced  more  and  more,  by  an  autonomous 
movement,  due  to  local  conditions  against  which  this  exten- 
sion, too  far  away  and  too  feeble,  can  do  nothing. 


I'OTT  S     DISEASK,     ni'DllKS^MI-.M-    OF     I  III;    (.llfHOSITY         aG5 

On  (lie  ciiiilraiN ,  willi  I  he  large  rcnolralcd  plasler  wliicli 
allows  ol' a  precise  and  (lincl  |)rcssure  uii  (lie  ili-^[)laced  verlobrac, 
not  onlv  arc  llicv  uiiahir   li>  fall  hack  liulhcr.    hiil,  under    the 


Fig.  234.  —   Hie  child  in  (Le  preceding  figure,  five  years  after  commencement 
of  treatment. 


influence  of  this  conlinuous  pushing  from  behind  forwards  they 
return  gradually  into  line. 

Reason  says  it  and  experience  demonstrates  it.      It  is  enough 


>M 


POTT  S    DISEASE. 


REDRESSMEXT    OF    THE    GIBBOSITY 


to  look  at  the  examples  here  given  of  corrections  made  by  us  in 
this  way,  to  be  convinced.      (Fig.  227  to  240). 

Conclusion.       In   the  same  way   that  a  fracture    suggests 
plaster  immediately,  Pott's  disease  should  henceforth  suggest 


Fig.   235.  —  Lucien  B  ...,  rue  de  Rivoli,  Paris.     Gibbosity  claling  eigbt  years. 


to  you  the  plaster  corset.  It  would  even  be  easy  to  maintain 
that  plaster  is  much  more  indispensal>le  in  the  case  of  Pott's 
disease  with  gibbosity  than  in  the  case  of  ordinary  traumatic 
fracture,  where  displacement,  or  even  a  tendency  to  displace- 
ment, does  not  always  exist. 


POTT  S    DISKASE. 


TIIF    THEATMENT   Ol'    ABSCESSES 


267 


^1  Cask    —  POTT'S  DISEASE  WITH  ABSCESS 

Axiom.  —  Take  care  above    everythinji:   not  to    open 
the  abscess,    nor   to  allow  it  to  open;  lor.    if  il    is  opened. 


Fig.   236.  —  The  same,  six  years  after  commencomenl  of  treatment. 

it    will   scarcely    ever  heal ;    a  fistula   will  remain   which  will 
become  infected  and  sooner  or  later,  end  in  death. 

Here  there  is   no   discussion    needed  as    to    the    treatment 


2  68  ABSTENTION    IN    THE    CASE    OF    DEEP   ABSCESSES 

which  should  be  followed.      Opinion  is  unanimous  among  well 
informed  surgeons. 

Even  in  the  case  of  a  retro-pharyngeal  abscess  in  Pott's 
disease  of  the   suh-occipital  region,   the  abscess  must  not  be 


Fig.   237.   —  MarfliaG.,  Algiers.      Gibbosity  ten  months  before  arriving  at  Berck. 

Opened,  but  if  there  should  be  grave  and  pressing  functional 
troubles,  puncture  the  collection  by  Avay  of  the  neck,  entering 
the  skin  at  the  side.      (Y.  p.  344  for  details  of  this  technique). 

The  Formula  for  the  Treatment  of  Abscesses 

Here  it  is  for  the  different  varieties. 

a)  Leave  the  abscess  alone,  if  it  is  not  easily  accessible,  in 
which  case  the  skin  will  not  be  in  danger.  This  is  the  most 
frequent  case. 


I'lNCTlUES    AM)    INJKCTIONS    1-OU    S(  I'KUI  ICIAL    ABSCESSES       269 

/;)  It  is  permissible,  and  even  indicated,  to  treat  it  iCil  is 
easily  accessil.le.  allli(>ti';li  llie  skin  is  not  llirealened. 


Fig.  238.  —  The  cliilcl  in  the  preceding  figure,  three  and  a  half  years 
after  commencement  of  treatment. 


c)  One  ought  immediately  to  treat  it  Avhen  the  skin  is  in 
danger,  in  AAhich  case  it  is  easily  accessible. 

By   treating  it,  I  mean  puncture  and  injection  (v.  Ch.  III). 


aio 


TREATME>T    OF    FISTLL.E 


/i'"  Case.  —  POTT'S  DISEASE  WITH   FISTULA 

We  have  explained  (Chap.  Ill)  the  general  treatment  of 
tuberculous  fistula?. 

You  recollect  that  : 

a)  If  the  fistula  is  not  infected  (that  is  there  is  neither  fever 
nor   albuminuria),  one   must  inject    into   the   sinus   modifying 


Fig.    239.  —  David  Ter,-M.,  Tillis,  gibbosity  of  two  year's  standing. 

injections  (of  creosote  and  iodoform,  or  of  camphorated  naphtol) 
either  in  the  form  of  liquid  or  of  paste. 

h)  If  the  fistula  is  infected,  on  the  contrary,  injections  are 
bad;  the  treatment,  in  that  case,  is  summed  up  in  these  fev\^ 
words  :  make  certain  of  the  drainage,  rigorous  asepsis,  rest, 
general  treatment,  and  patience. 


J'"    CVSE     :     POTTS    DISEASK    WITH     PUl\r,YSlS  27  I 

b'"  Case.  —  POTT'S  DISEASE  WITH  PARALYSIS. 

a)  The  indication  is  lo  release  llic  cord  Irom  pressure  and 
lo  modify,  if  possible,  ils  circalalinn  and  its  internal  nutrition. 
See  figure  202,  page  24 1. 

How  are  we  lo  do  this  ? 


Fig.  2^0.  —  Tlie  same,  three  years  after  redressment. 

With  or  ^^itll0ul:  operation.^ 

6)  The  treatment /o  be  carried  oat  :  one  fulfds  the  indications 
by  gently  redressing  the  spine  and  by  exerting  afterwards  a 
gentle  and  continuous  pressure  over  the  affected  vertebra?,  by 
the  only  orthopedic  treatment ;  that  is.  by  the  application  of 
a  large  plaster  only,  with  a  dorsal  opening.  A^  liilst  surgical 
operations    are   nearly  always   useless,    and    even   very   often, 


272 


TREATMENT    OF    THE   PARA.LTSIS    OF    POTT  S   DISEASE 


harmful,    thev  ought   to  he  condemned   without  appeal   in  the 

treatment  of  paralysis,  just  as  in  that  of  abscess  by  gravitation. 

Indeed,  operations  do  20  times  more  harm  than  good,  not 


Fig.  2/10  bis.  ■ —  Germaine  B.,  aged  7  years,  of  Santiago,  Cliili.  —  Gibljosity  of  two 
and  a  half  years  standing.  —  (This  litUe  girl  was  so  restless  ani  intractable  that 
we  were  obliged  to  have  recourse  to  chloroform  in  order  to  apply  the  first  apparatus. 
The  child  was  put  to  sleep  and  supported  in  the  sitting  position;  see  page  35 1 
«  on  chloroformisation  in  applying  the  plaster  ».  The  child  having  been  «  made 
comfortable  »  by  wearing  the  first  apparatus,  it  was  possible  to  apply  the  others 
without  the  help  of  chloroform).  —  see  fig.  2^0  ler,  the  same  child  after  treatment. 

only  because  they  sho^v  a  considerable  immediate  mortality 
(nearly  ^o  per  cent),  but  because  they  leave  a  fistula,  that  is,  a 
complication  much  more  formidable,  without  contradiction, 


tiil:  i,au(;i;   I'l.Asiiiii   ,m:akl\   ai.w  a\s   ci  hi;s   iiii;  i 


'.V11AI.\-I.S      2~'6 


than  the  paralysis,  wliicli  one  wishes  locuie.  For,  |);iralvsis, 
roineiiibcr.  nia\  he  cured  sponlaneousl\ .  hiil  especially  il  niav  be 
cured  h\    orlluipi'dic  li-ealnienl  alone,  al\\a\s  or  Mearl\  ahvays. 


Fig.   24o  ter.  —  The  same  3   i  j  ■>  years  after  straightening 


Why  not  always?  Because  sometimes  it  is  a  question  of 
tuberculous  myelitis  against  which  our  treatment  is  less  precise 
and  less  certain. 

A  ery  often  one  observes  a  distinct  improvement  a  lew  hours 

Caiot.   —  In:lispensahle  orlhopeclics.  18 


2  7-4  TECHNIQUE    OF    THE    TREATMENT    OF    POTT  S    DISEASE 

after  the  application  of  tlie  apparatus.  The  two  legs  may  perhaps 
have  been  absolutely  motionless  for  more  than  six  months, 
and  behold,  on  the  first  evening,  they  move  a  little.  Two  or 
three  days  later,  the  heels  are  freely  raised  aboAe  the  level  of  the 
bed.  This  return  of  functional  activity  in  the  paralvsed  part 
occurs  almost  regularly.  Each  week  brings  about  a  new  impro- 
vement :  in  from  ,3  tn  g  months,  the  paralysis  has  disappeared, 
not  only  from  the  lower  limbs,  but  also  from  the  bladder  and 
intestine. 

2-1  PART.  —  THE  TECHMQUE 

On  the  whole,  the  treatment  may  be  reduced  to  two 
things  :  — 

A.  —  The  plaster  corset. 

B.  —  Puncture  and   injection,  when  there   is  abscess. 
I  have  laid  down  in  the  first  part   of  this  chapter  what  is 

desirable  to  be  done  :  I  am  going  to  describe  in  the  second 
part  how  it  ought  to  be  done. 

.4.  —  TECHNIQUE  OF  THE  PLASTER  APPARATUS 

How  to  make  a  >/ood  plasfei'  corset,  when  no  specialist  is  avai- 
lable, which  realises  all  the  required  conditions,  that  is,  onew^liich 
supports  w  ell  and  nevertheless  does  not  incommode  the  patient. 

A  plaster  corset  is  not  more  difficult  to  make  than  a  plaster 
for  the  leg.  which  nearly  all  practilinners  can  make  easily. 
The  only  difference  between  the  two  is  that  you  liave  learned 
to  make  the  latter,  but  not  the  plaster  corset. 

^A'ell.  I  have  undertaken  to  teach  you.  and  I  promise  you 
will  succeed  in  doing  it,  if  you  follow  faithfully  the  technical 
indications  I  give  you  here. 

Make  one  or  two  preliminary  rehearsals.  —  A^hat  I 
ask  of  you  is.  as  to  the  first  corset  you  have  to  apply,  to  make 
for  yourself  (one  or  tAvo  days  before)  one  or  tAvo  general 
rehearsals  on  a  "  mannequin  o.  or  on  some  healthy  subject  of 


TECHNIQUE    Ol'    THE    FLASTEU     COIISET 


MEDIUM    SIZE       270 


the  same  age  apprnxlmalcly  as  the  patient.  This  Avill  enable 
you  lo  test  the  ([uality  of  your  plaster,  to  train  yourself,  to 
educate  your  assistant,  ^\  ho  may  be  simply  your  own  domestic, 
if  you  cannot  secure  the  aid  of  a  trained  nurse. 


Fig.  2/11.  —  The  medium  plaster. 


Fig.  242.  —  The  large  plaster. 


This  rehearsal  is  always  possible  in  practice,  for  if,  for 
a  fracture,  the  plaster  must  be  applied  immediately,  you  may, 
in  Pott's  disease,  put  olT  for  one  or  two  days  the  application 
of  the  corset.  In  the  meantime,  the  patient  should  be  kept  at 
rest  in  the  recumbent  position. 

Choice  of  Model  of  Plaster  Corset. 

There  are  three  models  :  the  large  plaster,  having  the  upper 


276     pott's   disease.    TECHNIQUE   OF   THE   MEDIUM    PLASTEU 

part  in  the  form  of  a  funnel  or  a  tray  enclosing  the  base  of  the 
skull  (fig.  242);  the  medium  plaster,  iviih  an  officer's  collar 
(fig.  2I11),  and  the  small  plaster  without  a  collar. 

They  differ  only  in  their  upper  parts,  all  of  them  stop 
beloAY  from  2  to  3  cm.  above  the  great  trochanter. 

The  choice  of  apparatus  depends  on  the  situation  of  the 
affection. 

For  Pott's  disease  below  the  6*''  dorsal  vertebra,  and 
for  lumbar  Pott's  disease,  we  use  a  medium  apparatus  with 
a  straight  collar. 

For  Pott's  disease  of  the  cervical  or  upper  dorsal  regions, 
above  the  sixth  dorsal  vertebra,  and  for  all  Pott's  diseases 
with  paralysis,  Avithout  distinction  of  situation,  it  is  necessary 
to  apply  the  large  apparatus  with  the  funnel-shaped  upper  part. 

The  small  apparatus  without  a  collar  ought  to  be 
reserved  as  an  apparatus  for  convalescence,  for  Pott's  disease 
of  the  lower  dorsal  or  lumbar  regions. 

/.   —  The   medium  apparatus. 

We  jwill  describe  first  the  construction  of  the  medium 
plaster,  which  is  of  the  three,  that  most  used;  we  will  point 
out  as  Ave  proceed  Aarious  peculiarities  proper  to  the  other  tAvo. 

Position  of  the  patient.  —  «  Stretch,  but  do  not 
suspend.  » 

The  [apparatus  should  ^  be  made  Avith  the  subject  in  the 
upright  position ;  one  supports  him  only,  AA'ithout  really  sus- 
pending him. 

Make,  in  a  Avord,  extension  only,  in  such  a  Avay  that  the 
heels  do  not  leave  the  ground  (fig.  243,  244)-  This  tension  is, 
first,  absolutely  harmless,  as  you  may  guess,  even  in  enfeebled 
subjects ;  second,  it  is  A-ery  Avell  tolerated  by  everybody,  for  the 
10  or  12  minutes  necessary  for  the  construction  of  the  appa- 
ratus, including  the  setting  of  the  plaster. 

If  you  adhere  to  this  formula,  you  have  gained  everything 


iiir:  PATiiAT   I  I'UKiiir. 


TENSION    NOT    SUSPENSION 


277 


arnl   lost  iiolliiiig  in  making  the  apparatus    in  the  upright 

position  lallier  than  in  tlie  liorizorilal  position  ' . 

The  suhject    will    llius    Ix'    better   adjusted    willioul    being 


-7   J  .T 
Fig.  2^3.  —  Strelch  and  do  not  suspend.  Fig.  24i. 

In  figure  2i3,  the  cord  has  not  laeen  tightened.  One  sees  in  fig.  244,  that  in  pulling 
on  the  head,  one  has  rectified  the  attitude  and  even  corrected  (slightly)  the 
gibbosity  without  the  feet  of  the  patient  quitlimj  the  fjroimd. 


fatigued,  and  you  Avill  have  infinitely  more  facility  for  construc- 
ting your  plaster  regularly  and  precisely. 

(a)  The  supporting  apparatus.  —  The  appliance  for 
supporting  the  patient  should  be,  in  default  of  a  pulley,  a  simple 
cord  fixed  to  a  hook  in  the  ceiling  or  in  a  doorway.      The  cord 

I.  For  paralysed  subjects,  you  \\ould  construct  the  apparatus  in  the  sitting 
posture,  which  gives  sufficient  traction  (to  free  tlie  spinal  cord)  and  not  too 
much  (lo  prevent  sudden  injury  to  the  tuljerculous  focus,  and  later  on,  an 
abrasion  of  the  chin)     (fig.  2  45  and  2  46). 


2lt 


PLASTER   CORSET. 


SLPPORTl^SG   APPARATUS 


has  at  its  extremity  the  centre  of  a  horizontal  bar  of  Avood  or 


Fig.  2^5.  —  Pelvi-support  made  up  of  a  bicycle  saddle  on  which  is  seated 
the  paralysed  patient,  during  the  construction  of  the  apparatus. 
Fig     246.  —  His  thighs  are  a  little  flexed  in  order  to  free  the  ischia  and   render  the- 
support  more  stable,  but  not  too  much  flexed  to  hinder  the  exact  application  of  the 
plaster  in  front.     One  steadies  the  patient  by  pressing  on  the  knees. 

metal,  furnished  at  each  end  Avith  a    groove  to  retain  the  two 
terminal  buckles  of  the  occipito-mental  straps. 

But,  -without  pulley  and  without  hook,  you  may  anywhere 
improvise  a  suspensory  apparatus,  by   means   of  a   step  ladder 


THE    OCCII'ITO-MENT.VL   STR.VI' 


279 


(fig.  2^7)  over  llio  lop  of  which  you  pass  the  cord  sustaining 
the  liorizontal  har  at  a  distance  from  the  ground  calculated  from 
tlie  heiglit  of  the  patient. 

It  is  easy,  willi  or  without  a  pulley,  to  regulate  the  height 


2^7.  —  Sustention  apparatus  improvised  with  a  step  ladder. 


of  the  horizontal  bar,  either  hy  lengthening  or  shortening  the 
cord,  or  by  approximating  or  separating  the  feet  of  the  ladder. 

(h)  The  occipito-mental  strap.  —  The  patient  is  bound  to 
the  supporting  apparatus  by  a  strap  or  collar-piece  (fig.  247)- 

With  an  ordinary  linen  bandage  and  two  safety  pins,  one 
makes  on  the  spot  a  girth  Avhich  can  with   advantage  take  the 


280 


TECHNIQUE  OF  THE  PLASTER  CORSET. 


THE  GIRTH 


place  of  all  the  Sayre's  collars,  or  of  those  sold  by  the  instru- 
ment makers. 

The  figures  following  show  the  method  of  procedure.     You 


Fig.  248.  —  To  make  a  girlh,   take  a  bandage  of  ordinary  linen  ao  cm.  longer  than 
^     the  height  of  the  patient;  fold  it  in  two  and  knot  the  two  extremities  together. 


Fig.  2/ig.  —  Divide   this    large  loop  into    three    by  taking   the   bandage  between  the 
thumb  and  index  finger  of  each  hand  at  the  2  extremities  of  its  middle  third. 


Fig.  2  5o.  —  The  median  portion  of  the  loop  should  be  of  such  a  length,  that  when 
applied  (the  two  layers  superimposed)  on  the  face  of  the  patient  on  a  level  with  the 
nose,  the  points  held  by  the  fingers  and  thumbs  correspond  with  the  auditory  meatus. 

take  a  bandage  of  a  length  equal  to  the  height  of  the  patient 
measured  from  the  head  to  the  feet  (or  better  still,  20  cm. 
longer),  you  fold  this  bandage  into  two,  and  knot  the  two  free 


THE    OCCllTro-MEMM,    (ilHTII 


cxiiviuilies  logellior.  \n\i  have  lliiis  a  large  loop  (fig.  ^.f\8). 
\(ui  then  divide  this  single  loop  info  three  secondary  loops, 
one  median,  lo  embrace  the  base  of  ihc  head  (fig.  .i\(j  and 
fig.  -loo)  and  two  lateral  ones  (^^hich  arc  folded  upwards  as  soon 
as  the  girth  is  in  position),  to  hang  on  the  two  extremities  of 
tli(^  transverse  bar  of  the  sustention  ap[)aratus. 


Viii.    25i.  —  Tlie  lingers  are  replaced  hv  two  safety  pins. 

The  median  loop  ought  to  have  a  circumference  equal  to 
twice  the  distance  which  separates  (in  front)  the  two  auditory 
meatus  of  the  patient. 

\ou  measure  the  distance  between  one  ear  and  the  other  sim- 
ply with  the  middle  portion  of  the  bandage  held  thus  :   (fig.  2/19 


Fig.  252.  —  Placing  the  girth  in  position.  —  The  head  engaged  in  the  middle  loop 
ought  to  pass  easily,  but  not  too  much  so  :  only  one  centimetre  of  play  must  be' 
allowed  on  each  side  (if  it  is  more  or  less,  it  drags  on  the  pins  and  may  pullthem  out)- 

and  200)  with  two  lingers  on  each  side.  The  measure  taken, 
you  put  two  pins  transversely  in  place  of  your  fingers  (fig.  25i). 
So  much  for  the  dimensions  of  the  median  loop,  which  is 
most  important.  On  the  other  hand,  the  lateral  loops  are  not 
of  much  importance  :  it  is  sufficient  to  have  them  equal,  for 
their  inequality  may  produce  an  inclination  of  the  head  to  one 


282 


THE    OCCIPITO-MENTAL    GIRTH 


Fig.  253.  —  The  two  la%prs  of  the 
middle  loop  enclose  the  chin  and 
the  occiput.  When  the  lateral 
loops  are  released  the  pin  should 
be  a  centimetre  above  the  upper 
border  of  the  ear. 


Fii;.  2.14.  —  lou  fix  «ifh  a  ])in  one  end 
of  the  strip  to  the  centre  of  the  posterior 
handle  of  the  middle  loop. 

(One  sees  in  these  figures  small  squares  of 
cotton  wool  ■with  -which  you  protect  the 
skin  against  friction  bv  the  pins. 


side 


Fig,  255.  —  The  girth 
iinished  and  adapted  : 
a  seam  has  been  made 
instead  of  a  knot. 


which  must  he  avoided.  To  adjust  a  girth 
you  open  horizontally  the  middle  loop,  intro- 
ducing it  from  above  do^^n^vards  (fig.  262) 
to  the  root  of  the  neck,  lou  adapt  the  ante- 
rior layer  to  the  chin  and  the  posterior 
layer  to  the  occiput,  after  Avhich  you  release 
the  lateral  loops  in  order  to  pass  them  on 
to  the  extremities  of  the  horizontal  bar 
(fastening  them  to  the  grooves  if  there  are 
any).  This  being  done,  the  middle  loop 
Avill  describe  a  broken  circumference,  AAhich 
will  prevent  its  slipping  when  the  patient 
is  pulled  upwards,  and  it  will  slip  all  the 
less  as  he  is  pulled  upwards  (provided  that 
vou  have  siven  it  the  measurements  indi- 


THE    OCCII'ITO-MEMAL    Gllll  II 


283 


catcd  above).  Jiiil  if  llic   patient  pulls  on  the  f<irlh,  you  see 

tlial   the  chin  is  on   llic  same  level   as    the  occiput   (fi<,r   256), 

lliat  is  to  say  thai  iho  head  (ills  bachinanls. 

Normall\.  llir  chin  should  correspond  witli  ihe  level  of  the 


Fig.  25G.  Fig.   267. 

Compa^i^on  of  the  two  figures  shews  the  utility  of  the  posterior  strip. 

Fig.  20(3.  —  The  strip  is  missing  :  the  two  layers,  anterior  and  posterior,  being  equal, 
the  head  is  pulled  backwards.  —  Fig.  267.  —  The  posterior  strip  prevents  the 
pulling  backwards. 

lower  part  of  the  3"*  cervical  vertebra.  In  order  to  bring  it 
back  to  this  level  (the  normal)  Ave  take  a  supplementary  strip 
of  linen  (one  metre  in  length)  of  which  one  extremity  is 
pinned  transversely  over  the  middle  of  the  posterior  layer  of  the 
girth  (fig.  254),  whilst  the  other  free  extremity  Avill  be  pulled 
upwards  and,  as  soon  as  Ave  pull  upAvards,  it  Avill  tilt  the  head 
forAvards.  A^  e  pull  until  the  chin  returns  to  the  normal  leAel 
(fig.  257).  As  soon  as  this  is  done,  you  fix  at  this  degree 
of  tension  the  free  extremity  of  the  strip  by  rolling  it  and 
tying  it  round  the  centre  of  the  horizontal  bar  (fig.  aSy). 


284     pott's    disease.    TECH^'IQLE    OF    THE    PLASTER    CORSET 

I  would   advise   you,  so    as  not   to  fatigue  the  patient,  to 
adapt  and  test  the  girth  while  he  is  still   at  rest  on  the  table; 


Fig.  258.  —  Method  of  cutting  ttie  attelles  out  of  a  piece  of  muslin. 

—  you  may  even  leave  him  there  until    the  differents  parts  of 
the  corset  are  ready. 

Preparation  of  the  parts  of  the  Corset. 

The   apparatus  is   made   with   strips   and   plastered   attelles 
applied  over  a  jersey  (v.  on  Generalities,  chap.  I). 


l'Ui:i'AU  \  I  liiN    OF    STIUl'S     AM)     I'l.AS  lEnEl)    ATTELf.ES 


285 


Procure  :   i"'.      From   5  to  10  kilos  (so    as  to   have    "  too 
mucli")  white  plaster  of  Paris. 


Fij;.    25r).    —    Posterior  atlelle  (ora  in    the   middle  to   a   third  of  its    length  (widtli 
equal    to  one  half  the  circumference  of  the   trunk   +  2    to  3  cm  ) 

2"''  Some  common  stiff  gummed  muslin  No  8  ;  have  too 
much  of  that  also,  and  for  that  take  from  lo  to  20  metres 
according  to  the  age  of  the  patient. 


286 


PLASTER    CORSET. 


TREPARATIO"    OF    THE     PATIENT 


From  this  muslin,  cut  the  strips  and  the  altelles. 
a)  Make  some  strips  5  m.  long,  from  12  to  10  cm.   wide. 
Number  of  strips  :  —  2  for  a  child  from  3  to  5  years,  three 
for  a  child  of  from  6  lo  1 1  vears;  four 


14  years; 


five 


for  a   child  of  12  or 
or  six  for  an  adult. 

h)  Cut  also  3  attelies  (fig,  208)  :  two 
large  ones  for  strengthening  the  back 
and  front,  andasmall  one  forlhecollar. 

Their  thickness  is  three  sheets  of 
muslin  for  each  (fig.  208).  Thelength 
and  width  are  the  same  for  the  two  big 
ones  :  length  i  1/2  times  that  of  the 
trunk; — width,  1/2  the  circumference 
of  the  trunk,  plus  2  or  3  cm.  (fig.  2  5  9). 

The  length  of  ihe  small  attelle  is 
equal  to  one  turn  round  the  neck, 
plus  3  or  4  cm.  and  its  breadth  equal 
to  the  length  of  the  neck  (fig.  261). 
One  of  the  two  large  attelies  is  rent 
to  a  third  of  its  length  in  two  equal 
tails.  Finally,  the  edges  of  the  one 
and  of  the  other  are  slightly  incised 
at  several  points  by  a  few  cuts  of  the 
scissors,  to  facilitate  their  applica- 
Fig.  2G0.  -  Jersey,  .ooiienaeck-    tiou  around  the  trunk,  and  to  prevent 

piece,  and  cotton-wool  square      crcaseS   (fis".    26"). 

applied  over  the  thorax.  t^i  t    •  i  r  T 

^^  ihe  strips  and  squares  ot  musim 

being  cut  to  size,  Ave  pass  on  to  the  preparation  of  the  patient. 


Preparation  of  the  Patient. 

The  patient,  still   laid  down,  is  invested  with    the  jersey. 
Do   not  apply  cotton   avooP  because  it   is  difficult    to    spread 

I.  Or,    if  you  must  use  cotton  ^AOol,  see  that  it  lies  uniformly  and  in   as 
thin  la^er  as  possible,  2  mm.  at  most. 


IMITINC     IIIK     I'Aril.M'     IN     POSITION 


^87 


evenly.  Hallicr  use  a  Jciscn  (lifi.  lido).  oi-.  boiler,  Iwo  jerseys, 
one  over  I  lie  oilier  and  littin^^  well.  If  lliere  remain  any  folds 
obliterate  ibcm  by  *"  pinching"  in  I'roiiL 

The  hvo  edges  (anterior  and  posterior)  are  joined  together 
at  the  bottom,  between  the  legs,  by  means  of  two  salelN-pins. 
To  complete  tiic  n[)per  part  of  the  jersey,  prepare  a  neck-piece 
in  soft  cloth,  circular  antl  filling  well,  which  should  be  closed 
behind'.  (Fig.   261.) 

Prepare  also,    for   pulling   on   the  breasl.  over  the  jersey,  a 


Fig.  2GJ1.  Neck-piece    couiposcd  of  a   slilp  of  cotton  betwen  Iwo  folds  of  soft  muslin 
Undernealh,  one  sees  the  attelle  for  the  neck. 

square  of  cotton  wool  of  i  or  2  cm.  in  thickness,  and  the  length 
and  breadth  of  ihe  thorax.  This  wool  is  intended  to  facilitate, 
by  its  elasticity,  the  expansion  of  the  thoracic  cage  (fig.  260), 
and  it  will  be  possible  to  remove  it  afterwards,  Avhen  the  anterior 
opening  in  the  apparatus  has  been  made.  (v.  p.  3oo  and  3oi). 

The  cotlon-wool  square  and  the  neck  piece  thus  prepared 
will  not  be  put  in  place  until  the  patient  is  on  his  feet,  in  good 
position. 

The   patient   dressed  in    the  jersey,  is  afterwards  furnished 

I.  Failing  a  cloth  neck-piece,  you  may  use  a  circular  cravat,  made  with  a 
strip  of  cotton-wool  of  a  length  and  breadth  equal  to  the  height  and  circum- 
ference (or  better,  one  circumference  and  a  half)  of  the  neck,  and  1/2  cm.  in 
thickness,  which  one  places  between  two  folds  of  soft  muslin  of  the  same 
dimensions.  This  cravat  is  passed  round  the  neck,  the  centre  in  front  and  the 
two  extremities  held  over  the  nucha  by  an  assistant,  or  bv  a  stitch  or  a  safety 
pui,  until  ithasbeen  fixed  by  tlie  first  turn  of  plaster  bandage. 


288 


POTTS     DISEASE. 


PLASTER   CORSET. 


POSITIO.\   OF    THE   HEAD 


with  a  girth,  the  centre  of  the  anterior  layer  of  Avliich  corres- 
ponds with  the  point  of  the  chin,  and  the  posterior  layer  with 
the    occiput,    whilst  one    gently   raises   the   two   lateral    loops 


Fig.  262.  Fig.  263. 

To  the  left  of  the  reader,  the  bad  application  of  the  chin  piece  which,  placed 
too  far  back,  slips  back  and  strangles.  To  the  right,  the  good  application  of  the 
piece;  it  embraces  the  chin  after  the  fashion  of  a  sling,  the  point  of  the  chin 
corresponding  with  the  centre  of  the  breadth  of  strip. 


(fig.    262  and  263).      One  protects  the   ears   from  the   lateral 
pins  by  two  small  pieces  of  cotton  aaooI. 


Position  of  the  Patient. 


The  patient  is  placed  upright,  beneath  the  sustention 
apparatus ;  the  two  loops  of  the  girth  are  placed  in  the  grooves 
of  the  horizontal  bar,  at  about  10  cm.  from  the  centre,  at  any 
rate  at  an  equal  distance  from  the  centre,  so  that  there  is  no 
inclination  of  the  head  to  one  side.  To  lower  the  chin  to  the 
desired   level,    you  then   pull   on  the  second  strip,    and   fix  it 


ONE    USES    HERE    STRIPS    PLASTERED    HEIOUEIIAM)  289 

it  in  tiiis  position  by  lying  the  strip  round  the   middle  ol    the 
bar.  (v.  fig.  a56.) 

One  verifies  the  height  of  the  middle  cord,  rectifying  it 
with  care,  shortening  it  or  lengthening  it,  unlil  the  patient  is 
•'  extended  "  to  the  required  degree,  that  is,  just  up  to  the 
point  where  the  heels  leave  the  ground,  and  no  more. 

"^ou  satisfy  yourself  that  the  patient  is  at  his  ease,  and  even, 
if  I  may  say  so,  quite  comfortable.  His  hands  are  held  by 
some  member  of  his  family,  the  arms  removed  from  the  trunk 
at  an  angle  of  ^o°;  this  is  only  a  fictitious  support,  a  "  moral  " 
support.  Another  person  keeps  in  position,  for  a  moment, 
the  pre-thoracic  square  and  the  woollen  cravat  —  until  the  first 
turn  of  the  bandage  fixes  them  in  their  place. 

Immediately  afterwards  you  pass  on  to  the  construction  of 
the  plaster. 

Construction  of  the  Apparatus. 

1st.     Preparation  of  the  plaster  cream. 

It  has  already  been  said  in  the  "  Generalities"  (v.  p.  20) 
that  for  plaster  corsets  it  is  much  better  to  use  plaster 
strips,  prepared  a  little  (very  little)  beforehand,  rather  than 
bandages  steeped  at  the  time  in  the  plaster  cream. 

In  the  second  place,  for  a  corset,  the  cream,  which  serves 
as  "  mortar  "  and  for  plastering  the  attelles,  ought  to  be 
thinner  than  that  for  small  plasters  of  the  leg  and  arm  (one 
takes  4  cups  of  water,  instead  of  3,  to  5  cups  of  plaster). 

This  thinner  cream  will  set  in  about  fifteen  minutes  (not 
as  before,  in  ten).  As  you  require  a  few  minutes  to  verify 
the  posture  and  to  model  the  apparatus  before  the  plaster  sets, 
you  have  then  from  10  to  12  minutes  to  construct  the  plaster; 
10  to  12  minutes  are  sufficient,  and  are  necessary,  when  you 
are  not  in  ••  training".  Moreover  you  will  have  ascertained  all 
this  in  the  rehearsal  you  have  made.  If  you  have  noticed  that 
it  took  you  from  i5  to  1 8  minutes  to  build  a  "  trial"  apparatus, 
you  may  add,   for  the  real  plaster,  half  a  cup  full  of  water  to 

Calot.  —  Indispensaljle  orthopedics.  19 


890 


CONSTRUCTION    OF    THE    PLASTER    CORSET 


the  quantity  mentioned  above,  which  retards  the  setting  by 
4  or  5  minutes  more  —  and,  on  the  other  hand,  if  you  have 
only  taken  5  or  6  minutes  over  the  trial  plaster  (personally  we 


Fig.  264  — Application  of  the  first  strip. 
Begin  at  the  angle  of  the  left  scapu- 
la (i);  then  the  strip  is  led  over  the 
right  shoulder,  passing  diagonally  over 
the  thorax:,  crossing  the  left  axilla  (2), 
finally  it  is  conducted  horizontally 
behind,  from  the  left  axilla  to  the 
right  (3). 


Fig.  265.  —  The  first  bandage  then 
passes  diagonally  over  the  anterior 
aspect  of  the  thorax,  from  the  right 
axilla  to  the  left  shoulder  (4):  it 
is  afterwards  conducted  diagonally 
behind,  from  the  left  shoulder  to  the 
right  axilla  (5)  ;  finally  it  passes  in 
front,  going  horizontally  from  the 
rioht  axilla  to  the  left  axilla. 


take  2  or  3  minutes  for  constructing  a  corset),  or,  if  the  setting 
of  your  plaster  is  not  complete  under'  20  minutes,  for  example. 


ONE  OUGHT  I'"'^  TO  SPREAD  OUT  THE  PLASTERED  STRIP    2(J  I 

yon  add  for  llio  real  apparatus,  hall"  a  cup  full  of  plaster,  which 
advances  llio  sellinj^  1)\   alxtul  3  inirmlcs. 

The  plastering  of  the  attelles  is  dune  in  tiie  ordinary  way 
(see  p.  25    and    fiir.  9)  by    dipping  I  hern   in    a   basin  half  full 


f       I     \ 

Fig.   266.  —  Placing  in  position  Ihe  posterior  attelle. 


of  cream.  Your  assistant  should  do  this  plastering,  Avhile  you 
apply  the  first  strip  (or  you  do  it  yourself  before  the  appli- 
cation, if  you  have  not  an  expert  assistant).  The  three  attelles 
are  left  in  the  basin,  awaiting  the  moment  for  their  applica- 
tion. 


202       2''°,   APPLY    THE    STRIPS    EXACTLT  ;   O^^,    BUT   WITHOUT  PRESSURE 


2""'.  The  method  of  application  of  the  strips. 

Remember    the    3   fundamental    recommendations    :    it   is 

necessary  to  spread  out  the 
strip,  to  apply  it  exactly,  but 
without  pressure. 

AAhat  should  be  the  course 
taken  by  the  strips  ?  Not  compli- 
cated in  any  way  (fig.  264  and 
265).  You  cover  the  region  of 
the  shoulders  by  some  diagonal 
turns  and  figures  of  8  over  the 
region  of  the  shoulders,  always 
avoiding  ridges  being  made,  in- 
cising the  edges,  if  need  be, 
when  they  are  too  tight. 

Afterwards  you  go  by  circular 
turns  from  the  axilla  downwards, 
as  far  as  needed ,  without 
reverses  (v.  p.  3o  and  3i). 
AYith  a  few  cuts  with  the  scissors 
at  the  edges,  these  circular  ban- 
dages, moist  and  delicate,  are 
easily  applied,  even  over  a  trunk 
Fig.    267.  —  After  the  application  of  wliich  is  not  regular  in  form. 

the   attelle,  some  incisions  are  made  j;a(>|^   ^^j.^   ^f  t]^g   g^pjp   ought 

in  its  edojes  to  facilitate  its  adaptation.  /  /       <•    i 

The   right    tail    is    already   llattened  tO   COVCT  nearly  I  /  4  of  the  prece- 

down  on  the  shoulder,  the  left  tail  is  rjirio-   turn 

still  raised.  —  The  two  tails  must  go  t         i   ■                    •                t        ^        n 

round  the  shoulders  in  front  and  unite  In   thlS    Way    IS    made  the   first 

below  the  axilla  at  the  lateral  borders  continUOUS      COVeHng       of      the 

of  the  attelle  (k. /jr.   269).  ,         1       r\         1         1                'U        fr 

trunk.  One  bandage  will  sullice 
for  a  little  child ;  it  may  take  two  or  three  for  adolescents  and 
adults. 

3^'^.  Application  of  the  Attelles. 
One  then  applies  the  attelles,  having  taken  care  to  spread  them 
out,  after  having  squeezed  them. 


pott's    disease.    TECHNIQLE    OF    THE    PLASTER    CORSEXJllagS 

a)  One  commences  with  the  posterior  one  or  '•  cliasuble". 


137.  J'-^- 
Fig.  268.  —  Placing  in  position  the 
circular  at  telle  of  the  shoulder  and  the 
anterior  attelle,  of  which  the  inferior 
third  is  raised  up :  that  which  is 
represented  here  is  too  narrow,  it 
ought  to  overlap  the  axillary  line  by 
one  or  two  centimetres. 


Fig.  269.  —  The  attelles  in  place  :  one 
sees  the  extremity  of  the  superior  tail 
of  the  "  chasuble"'  under  the  axilla, 
and  the  inferior  third  of  the  anterior 
attelle  raised  up  over  the  abdomen  : 
also  the  attelle  for  the  neck  over  the 
woollen  neck-piece. 


The  inferior  edge  is  placed  at  the  level  of  the  tip  of  the  coccyx, 


294 


PLASTER    CORSET.     APPLICATIO?*    OF    THE    ATTELLES 


SO  that  the  back  is  covered  by  two  thirds  of  the  attelle.  The 
upper  third,  which  passes  upwards  over  the  scapulae,  has  been 
split  into  two  tails  of  equal  width,  to  go  over  the  shoulders 
(fig.  266);  each  tail  passes  over,  then  in  front  of  the  correspond- 


Fig.  270.  —  Modelling  the  apparatus  above  the  iliac  crests. 

ing  shoulder,  afterwards  under  the  axilla,  and  returns  to  unite 
with  die  corresponding  lateral  border  of  the  posterior  part  of 
the  attelle.  Some  incisions,  made  here  and  there,  into  the 
edges  of  each  tail  (fig.  267)  facilitate  it's  appUcation  and  it's 
exact  adaptation  to  the  circumference  of  the  shoulder. 

b)  One  takes  afterwards  the  anterior  attelle  and  applies 
it   first    by   it's    superior   border  a  finger's   breadth   above  the 


POTT  S    DISEASE.    MODELLING    THE    PLASTER  29O 

clavicles;  it  covers  liic  tails  of  the  preceding  alleile,  then 
descends  over  the  chest  and  abdomen.  The  inferior  i/3  hangs 
below  the  pubes;  one  folds  this  apron  over  the  middle  i/3, 
even  with  the  abdomen  ;  the  fold  corresponds  with  the  line  of 
the  trochanters;  this  will  be  the  lower  border  of  the  plaster 
(fig.  268,  269). 

c)  The  attelle  for  the  neck  is  applied  like  a  circular 
cravat  (fig.  i?68)  over  the  woollen  covering.  The  upper  edge 
of  this  piece  stops  at  one  centimetre  below  the  upper  edge  of 
ihe  woollen  cravat  (fig.  269),  and  the  lower  edge  encroaches 
upon  the  upper  parts  of  the  two  preceding  attelles.  It  is 
sufficient  to  roll  it  without  any  pressure  (nevertheless  exactly), 
to  avoid  with  certainty  all  constriction  of  the  neck.  In  a  word 
you  apply  it  as  you  do  your  collar ;  were  it  made  of  sheet-iron 
and  placed  directly  on  the  skin,  it  would  not,  however, 
compress  your  larynx. 

The  three  attelles  being  placed  in  position,  which  is 
very  rapidly  done  (a  minute  for  each  if  one  is  assisted  by  one 
or  tAvo  persons),  you  join  them  by  rolling  over  them  a  plas- 
tered strip  in  the  way  mentioned  for  the  under  one,  that  is.  in 
figures-of-8  arid  circular  turns. 

One  strip  over  the  attelles  and  one  below  (tAvo  in  all) 
suffice  to  construct  the  apparatus  for  children  of  less  than  six 
years,  but  4  or  5  strips  (in  all)  are  necessary,  as  we  have  said, 
for  subjects  of  from  tAvelve  to  fifteen  years. 

You  may  have  to  use  6  or  even  7  strips  (Avithout  counting 
the  attelles)  for  adolescents  and  adults  rather  big  and  fat, 
to  give  thickness  and  the  required  resistance  to  the  plaster. 

Between  the  different  layers  of  the  strips  and  over  the 
last,  one  spreads,  as  has  been  mentioned  in  the  generalities, 
a  layer  one  or  two  millimetres  thick  of  plaster  cream.  — 
It  is  the  mortar  Avhich  unites  into  one  solid  block  the  different 
planes  of  the  apparatus. 


296 


POTT  S    DISEASE.     MODELLING    THE    PLASTER    CORSET 


4*.  Modelling  the  plaster. 

The  apparatus  is  finished.      Nothing  remains  but  to  model  it 
over  the  pelvis  and  around  the  shoulders  (fig.  270  to  272). 

1st.  Over  the  pelvis  :  you 
model  by  embracing  with 
both  hands,  half-closed,  the 
spines  and  iliac  crests,  pres- 
sing the  plaster  very  firmly 
above  the  superior  border 
and  inwards  along  the 
anterior  border  of  the  hip- 
bone Avith  the  pulp  of  the 
fingers  (fig.  270)  Avhilst  the 
palms  of  the  hands  press 
Ijeliiw  the  iliac  crests.  The 
spines  and  the  crests  are 
thus  capped,  encased  by  the 
apparatus,  without  any  risk 
of  sloughing  (fig.  271 ). 

2°''.  Over  the  contour  of 
the  shoulders,  Avhere  an  assis- 
tant '  applies  the  plaster  AA'ith 
very  light  pressure  (fig.  271 ). 
One  occupies,  in  effecting 
the  modelling,  the  feAA'  mi- 
Fig.    271.  — Modelling  the  shoulders  and  iliac    ririJ-As  which   Drecede  the  SCt- 
crests,  in  a  large  plaster  :  the  modellincr  is 

done  in  the  same  way  as  in  a  medium  plaster,  tmg  of  the  plaster,  aCCOrdmg 
—  Another  assistant  models  at  the  same  ^q  ^\^q  calculation  laid  dOAAn 
time   the  sacrum  and  pubes  (that  assistant    ,      „  t     •        i-  i 

has  not  been  shewn  here  in  order  to  leave  before.  It  IS  then,  at  about 
the  figure  more  distinct,  but  see  the  figure  (^q  fifteenth  miuute,  the  plas- 
on  the  followinsr  pase.  .  i  i  • 

terbemg  set,  that  the  patient 
can   be  remoA'ed  from  the  sustention   apparatus.     To   do  this. 


I.  A  second  assistant  makes  it  fit  exacth   over  the  pubes  and  the  sacrum 
(v.  fig.  272). 


pott's    disease.     TRIMMlNf;     Till-     I'LASTER 


297 


open  out  llie  leot  oC  the  step-ladder,  or  loosen  the  cord;  llicn  pull 
fonvard,  lo  disengage  the  chin  piece  of  the  girth. 

Let  the  child  stand  upright  for  ten  minutes  more,  so  as  not 
lo  risk  hy  lying  him  down  too  soon,  the  cracking  of  the  appa- 
ratus; —  then  the  plaster  appearing  to  he  solid,  the  patient  is 


tig.  272.  —  Modelling  the  sacrum  and  pubes  in  a  large  or  medium  apparatus.     The 
iliac  crests  are  modelled  at  the  same  time.     (v.  preceding  figure  and  its  explanation). 

laid  down  —  placing  transversely  under  his  neck  a  small  roll  of 
cotton  wool  in  the  form  of  a  log,  or,  more  simply,  leaving  his 
head  to  overhang  the  end  of  the  table,  supporting  it  with  the  hand. 

5''\  Trimming  the  apparatus. 
A  quarter  of  an  hour  or  half  an  hour  afterwards  (with  the 
patient  lying  down)  you  proceed  to  trim  the  apparatus  (fig.  278), 


2q8 


POTT  S    DISEASE. 


TECHNIQUE    OF    THE    PLASTER 


which  is  done  with  a  bistoury  or  a  common  knife  well  sharpened. 
The  plaster  is  cut  (down  to  the  jersey  only)  : 
At  the  bottom,  below  the  iKac  spines,  cut  little  by  little, 
just  enough  to  allow  the  patient  to 
bend  the  thigh  to  a  right  angle,  if  it 
is  desired  that  he  should  walk  about 
with  the  apparatus.  Cut  out  less  if 
he  ought  to  remain  incumbent;  for 
the  legs  Avill  be  thus  someAvhat  res- 
trained, and  immobilization  will  be 
perfect. 

The  plaster  is  allowed  to  extend 
dowuAvards  in  the  sbape  of  a  point 
over  the  pubes  and  also  behind  over 
the  sacrum. 

At  each  side  of  the  shoulders  cut 
away  all  that  goes  beyond  the  scapulo- 
humeral articulation. 

The  arm  holes  are  freed  for 
2  c.  m.  so  as  to  allow  of  ease  in  the 
movements  of  the  arms. 

The  superior  border  of  the  collar 
is  pared  for  a  few  millimetres  to  make 
it  even. 

A  small  provisional  opening  is 
Fig.  .7II' Apparatus  with  offi-  ^^^de  afterAvards  over  the  front  of 

cer's   collar    and  a    provisional    the     Chest     tlirOUgll      wllich      CaU     be 
opening :  the  dotted  lines  shew      -,  ,  i  ,  ,  1      1  i  •       r         , 

the  limits  of  the  large  definite    ^^awn   the  COltOU  WOol  placed  in  frOUt 

opening  and  the  edge  of  the  of    the   Jersey.      Tliis    facilitates   the 

apparatus  after  trimmins.  \  0     ,1  .1  -.i 

movements    ot    the   thorax,    without 
damaging   the    soliditv    or    the    precision    of    the    apparatus. 


Strengthening  the  plaster. 

Suppose  that  the  plaster  is  too  Aveak,  all  over,  or  at  some  one 
point. 


now    TO   coNsoi.inA  IE   the   I'I.asteu  299 

II  may  happen  in  spile  til'  all  llie  precautions  taken  in 
laying  the  patient  down,  llial  llie  plaster  lias  cracked  during  tlie 
niana^uvrc  :  it  nia\  even  crack  oi-  become  crumpled  spontaneously. 


Fig.  27'!.  —  The  medium  apparatus  trimmed.  Permanent  anterior  opening. 

Here  is  the  way  you  remedy  this  :  You  pull  on  the  top  and 
the  bottom  of  the  apparatus  in  order  to  return  tlie  patient 
(lying  down  or  upright)  to  the  position  desired,  and  whilst  two 


3oo 


POTT  S     DISEASE. 


POLISHING    THE    APPARATUS 


assistants  maintain  this  position,  it  is  fixed  there,  by  the 
application  of  several  squares  of  plastered  muslin  over  the  weak 
places,  flattening  them  out  with  several  turns  of  bandage. 
Hold  it  so  until  the  setting  of  the  new  plastered  pieces. 

To  succeed  in  making  these  repairs,  it  is  well  to  commence 
by  spreading  over  the  part  you  wish  to  strengthen  a  layer  of 
rather  liquid  paste  (equal  parts  of  water  and  plaster)  and  it  is 
over   this  layer   of  paste    that  you  will    apply  the  squares  of 


Fig.  275.  —  Dorsal  opening  for  the  compression  of  the  affected  vertebrae     (m  a  large 

apparatus) . 

plastered  muslin,  of  a  single  thickness  and  one  by  one.  This 
precaution  is  absolutely  indispensable  when  it  is  desired  to 
repair  a  plaster  already  dry.  (For  the  details,  refer  to  the 
generalities  of  the  technique  of  plaster  apparatus,  chap.  I.) 

Polishing  the  apparatus. 

Two  days  after  it  has  been  constructed,  one  polishes  the 
plaster,  which  is  done  after  the  method  mentioned  in  the  gene- 
ralities, pages  79,  80  and  81. 

The  openings  in  the  plaster. 

i[\  or  48  hours  after  the  polishing,  you  vadkelhe,  permanent 
openings. 


now      K)    OPEN    THE    I'EASTEU    CORSET 


3oi 


In  culling  llie  openings  In  llie  plaster,  as  in  Uimming,  cut 
layer  alter  layer,  very  gently,  until  \ou  have  tlie  sensation  of 
no   longei-  touching  hard  plaster,   hul  the  tissue  oi"  the  jersey. 

Be  careful  not  lo  cut  inadvertently  through  the  jersey. 

With  a  little  practice  you  Avill  easily  succeed.  But  the 
safest  way  is  to  place  over  the  jersey,  at  the  points  where 
\ou  intend  making  the  openings  (over  tlie  gibbosity  or  at  any 
other  point),  a  square  of  cotton  wool  12  cm.  in  thickness, 
before   constructing   the    plaster.      Thanks   to   this  square,  you 


til 


hursal   opening  in  a  uiediuui   planter. 


will  be  able  to  make  an  opening  without  fear  of  wounding  the 
child.      The  double  jersey  also  gives  a  greater  security. 

P^.  Permanent  anterior  opening  (Cig.  2-fi.) 

It's  dimensions.  —  Each  lateral  part  of  the  plaster  has  a  width 
equal  to  about  a  quarter  the  width  of  the  breast,  at  the  level 
of  the  shoulders.  But  the  opening  widens  very  much  at  the 
lovyer  part,  extending  from  one  vertical  axillary  line  to  the 
other.  The  top  piece  is  3  or  4  cm.  high  and  the  bottom  one 
8  or  10  cm. 

2°''.  Dorsal  opening. 

This  is  made  at  the  same  time  as  the  preceding  one. 
In  the  case  of  a  gibbosity  unusually  pointed,  one   does  not 
Avait  for   2    or  3  days.      Ten   or  fifteen  hours  after  the  plaster 


3o2 


pott's    disease.    PLASTER    CORSET 


is  made,  the  dorsal  opening  is   cut  out,  so  as  to   be  perfectly 
certain  that  all  abrasion  of  the  skin  is  avoided,  (fig.  275). 


£r;g_  2']'].  —  The  llaps  ol'  the  jersey  are  held  by  an  assistant:  you  place  in  position 
the  square  of  cotton  wool,  >Yhich  you  carefully  spread  out  at  the  sides  between  the 
skin  and  the  jersey  by  means  of  your  fingers,  or  some  flat  instrument  (a  spatula). 

The  dorsal  opening  is  indispensable  in  all  apparatus  for 
Pott's  disease.     I    say  indispensable.      If  you  remove  a  piece 


Fig.  278.  —  The  dome  of  wool  projecting  through  the  dorsal  opening. 

from  the  dorsal  aspect  of  any  corset  or  apparatus,  even  if  this 
corset   has  been  applied   during  complete    suspension   of  the 


NECESSITY    OF    THE    DORSAL    OPENING 


3o3 


palienl,  and  ex[)ose  llie  bare  skin,  you  will  see  (fig.  276)  tliat 
llic    vorlchrcL'   do    iiol    loucli    llie    inner  surface  ot"  llie  corset; 


tig.  271J.  —  Compression  of  the  dome  by  means  of  a  band  of  strapping. 

there  may  even  be  a  gap  of  from  4  to  5  cm,  —  which  proves 
that  they  are  not  sufficiently  supported.     This  simple  examina- 


Fig.   280.  —  The  compression  is  completed. 

tion  explains  too  Avell  how,  in  the  ordinary  corsets  without 
a  dorsal  opening,  the  gibbosities  may  not  only  persist,  but 
become  aggravated. 


3o4 


POTT  S    DISEASE.    TECH>'IQUE    OF    DORSAL    COMPRESSION 


If  you  "wish  the  affected  vertebrfe  to  be  supported  constantly, 
you  see  that  it  is  necessary  to  place  there,  in  very  great  number, 


Fjo-.  281.  —  Schematic  sketch  of  a  large  apparatus  furnished  Avith  a  compressive 
tampon,  before  the  application  of  the  strapping  :  C.  section  of  the  plaster, 
interrupted  in  front  by  a  large  anterior  opening  (which  reaches  up  to  the  hyoid 
bone.  V.  fis;.  2/11);  J.  Jersey  turned  aside  at  the  edges  of  the  dorsal  opening  ;  T. 
squares  of  ayooI  forming  a  tampon  over  the  gibbosity :  —  P.  direction  of  the 
pressure  of  the  strapping  -which  acts  by  pushing  back  the  ^vool  tampon  and 
the  sibbositv  to  the  position  indicated  by  the  dotted  lines ;  —  R.  Points  of 
counter  pressure  of  the  apparatus  on  a  levehyith  the  scapular  girdle:  —  R'  Points 
of  counter-pressure  of  the  apparatus  at  the  level  of  the  pelvic  girdle. 

squares  of  elastic  wool,  in  order  to  exert  a  continuous  pressure 
upon  the  corresponding  vertebral  segments. 

Dimensions  of  the  dorsal  opening.     —  It  ought  to  extend  from 
3  or  4  cm.  on  each  side  of  the  affected  vertebral  segment  (fig.  275). 


TREATMENT    OF    POTT  S    DISEASE 


3o5 


The  plastered  piece  is  removed,  as  if  it  were  punclied  out, 
with  a  bistoury;  then  you  divide  diagonally  the  small  square 
of  exposed  jersey,  raise  up  the  flaps,  and  proceed  to  the 
compression. 

Technique  of  the  compression. 

You  commence  by  annointing  the  skin  willi  a  layer  of 
vaseline  of  one  or  two  millimetres 
in  thickness. 

Cut,  next,  squares  of  wool  a  little 
larger  than  the  opening  (fig.  276), 


Fig.  282.  —  The  gummed  bandage 
applied  and  partly  obscuring  the 
large  anterior  opening. 


Fig.  283.  —  The  anterior  opening  has 
been  freed  of  the  turns  of  bandage 
obscuring  the  opening  partly. 


and  of  I  cm.  in  thickness.  Cut  and  introduce  them  at  once 
between  the  affected  vertebrae  and  the  internal  wall  of  the  pillars 
of  the  opening  (fig.  277). 

Use  thusSto  lOsquares  of  wool  for  the  first  compression. 

The  wool    makes  a  projecting  dome  through  the   opening 

Calot.  —  Indispensable  orthopedics.  20 


3o6  TEGHMQUE    OF    DORSAL    COMPRESSION 

(fig.  278).  The  projecting  wool  is  forced  into  tlie  opening  until 
level  with  the  plaster,  with  one  or  two  strips  of  sticking 
plaster,  moistened,  rolled  round  the  apparatus,  and  exercising 
a  strong  compression  over  the  woollen  dome  (fig.  279). 
The  dome  diminishes  by  degrees  until  it  is  entirely  effaced 
(fig.  280  and  281). 

The  sticking-plaster  adheres  very  soon  firmly  all  round  the 
plaster,  and  a  few  hours  later,  you  may  cut  out  and  remove 
the  part  of  the  strip  which  covers  the  anterior  opening  :  Avhich 
restores  to  respiration  it's  complete  liberty  (fig.  282  and  288). 

The  number  of  cotton-wool  squares  varies  according  to  the 
case. 

a.  There  is  no  gibbosity; 

You  use  8  to  10  squares  (to  prevent  the  appearance  of  a 
gibbosity). 

b.  There  is  a  gibbosity; 

You  can  then  go  up  to  i5  or  18  squares  of  i  cm.  not  at 
once,  but  at  the  third  or  fourth  compression,  Avhen  the  space 
Avhich  is  found  betAveen  the  vertebrae  and  the  plaster  has  become 
more  pronounced. 

18  squares  seems  enormous,  but  they  adapt  themselves  in 
an  incredible  way,  and  Ave  have  never  seen  any  inconvenience 
from  a  compression  carried  to  this  extent  in  a  gradual  way. 

The  gibbosity  is  by  this  means,  progressively  pushed 
forwards,  Avhilst  the  vertebrae  above  and  below  tend,  on  the 
other  hand,  to  return  towards  the  posterior  wall  of  the  appa- 
ratus, because  of  the  immobilisation  of  the  shoulders  and  the 
pelvis  (fig.  281).  The  condition  is  comparable  to  that  of  a  child 
leaning  backwards  against  a  vertical  ladder,  to  which  he  is 
firmly  attached  by  the  shoulders  and  pelvis,  whilst  the  middle 
part  of  the  back  is  pushed  forwards  Avith  the  hand. 

All  this  is  done  sloA\"ly,  methodically.  So  much  so  that 
this  very  efficacious  compression,  Avhich  is  as  energetic  as 
you    Avish,   is,   nevertheless,    extremely   gentle    and    very 


TREATMENT    OK    POTT  S    DISEASE 


807 


well  tolerated.  It  produces  no  sloughing  ',  instead  of  which, 
with  an  apparaUis  unopened  heliind,  sloughing  is  nearly  cons- 
tant although  the  [)ressure  be  inappreciable. 

//.  —  The  large  plastered  corset  for  Pott's  disease. 

The  larf/c  plaslei'  encases  the  base  of  iho  skull. 


Fig.   28^.  —  Oblique  occipito-mental  era-  Fig.    280.    —  Tiie  metliod  of  rolling  the 

vat  and  woollen  turn,  the  one  as  it  were  first    plastered    strip   round    the  head 

the  equator,  the  other  the  meridian,  to  at  the  equator  and  at  the  meridian, 
complete  the  protection  of  the  head. 

The  posture  of  the  patient,  the  sustention  apparatus,  and  the 
occipito-mental  girth,  are  just  the  same  as  for  the  medium  plaster. 


I.  Or  almost  never;  v.  p.  71  and  74  tlie  mean?  of  detecting  and  treating 
slouo:lis. 


3o8   THE  CONSTRUCTION  OF  THE  ((  LARGE  ))  PLASTER  CORSET 


Here  are  the  differences  between  the  two  apparatus. 

The  clothing.  —  As  above,  the  jersey  and  woollen  pad 
over  the  chest.  In  place  of  the  circular  cravat,  you  use  here, 
to  complete  the  jersey,  an  oblique  woollen  cravat,  embracing 
the  chin  and  the  occiput,  following  consequently  the  occipito- 


-orj 


-f7 


0-.  286.  —  Strengthening  squares  and 
occipi  to-mental  attelle  placed  in  position 
over  the  first  strip  for  the  sub-clavi- 
cular portion  of  the  large  apparatus. 


J^ 


Fig.  287.  —  These  two  pads  are 
fixed  round  the  head  with  a 
plastered  strip. 


mental  circumference  (fig.  28/i).  An  assistant  holds  the  two 
extremities  of  the  cravat  over  the  middle  line  behind,  until  the 
first  turn  of  bandage  has  been  applied.  You  complete  the 
covering  of  the  base  of  the  skull  by  two  turns  of  wool  one 
centimetre  in  thickness,  of  which  one  is  carried  perpendi- 
cularly to    the  cravat,  as    an  equator,  from   the  forehead    to 


THKATMENT    OF    I'OTT  S    DISEASE 


Sog 


the  nucha, llie  titlier  circuhulv  round  llic  neck  and  the  nucha. 
Preparation  of  the  attelles.  —  Th(  two  large  pieces  for 
the  trunk  are  the  same;  but,  instead  ol  the  circular  cravat, 
we  prepare  two  square  pieces,  of  Irom  i5  to  ;?5  centimetres 
according  to  the  size  of  the  subject  (having  the  usual  three 
thicknesses);  these  will  be  placed,  one  in  front,  the  other  behind. 


Fig.  288.  —  The  upper  end  of  the  apparatus  has  been  cut  over  the  forehead  and  the 
two  pieces  turned  over  at  the  sides  ;  remove  the  lateral  pins  of  the  girth  which 
you  can  thea  cautiously  pull  away  by  making  it  slide.  But  if  you  have  cut 
the  two  tails  on  one  side,  you  have  only  to  pull  towards  you  from  the  other  side  ; 
this  second  proceeding  is  much  easier. 

to   make  the  armature   of  the   cranio-cervical   portion    of  the 
apparatus  (fig.  286). 

The  application  of  the  bandages. 

The  first  plastered  strip  is  rolled  round  the  head  in 
meridians  and  in  equators,  commencing  rather  by  the  meri- 
dians going  from  the  vertex  doAvnwards  to  the  jaw  (fig.  285). 
You  repass  three  times  and  cut  the  strip.      Then  you  make  three 


3io 


TECHNIQUE    OF    THE     «    LARGE     ))    PLASTER, 


or  four  turns  at  the  equator,  from  the  forehead  to  the  nucha.  Add 
two  or  three  circular  turns,  rather  loosely  round  the  neck. 

Afterwards,  you  roll  one  or  two  bandages  over  the  trunk, 
as  for  the  medium  plaster  (see  above). 

Application  of  the  attelles.  —  The  two  attelles  for  the 
trunk  are  placed  as  in  the  preceding  apparatus :  the  two 
supplementary  square  attelles  are  placed  the  one  before, 
from  the  chin  to  the  two  clavicles,,  the  other  behind,  from 


Fig.  289.  —  When  the  child  is  recumbent,  place  a  bolster  under  his  neck  so  that  the 
top  of  the  head  does  not  rest  on  the  bed, 

the  vertex  to  'the  scapulse,  encroaching,  consequently,  more 
or  less  extensively  upon  the  large  attelles  of  the  trunk  (fig.  286). 

Then  you  keep  in  position  the  two  attelles  for  the  head  by 
some  turns  of  bandages  in  the  meridians  and  equators  (fig.  287) 
as  above,  and  the  attelles  of  the  trunk  by  a  bandage  rolled  in 
the  form  of  an  8  in  circular  turns ;  lastly,  you  unite  the  head 
and  the  trunk  by  a  few  intermediary  circular  turns. 

You  use,  in  the  construction  of  a  large  plaster,  one  or  two 
bandages  more  than  for  the  preceding,  —  according  as  you 
are  dealing  with  a  child  or  an  adult. 

After  that  you  pass  on  to  the  modelling,  which  is  done, 
over  the  shoulders  and  the  pelvis,  in  the  same  Avay  as  in  the 
first  apparatus  (fig.  271,   272). 


IIUMMI.NG    TIIK    I'LASTEU 


3ll 


It  will  Hot  alwiiNs  be  necessary  to  model  the  plaster  with 
llic  hands  over  the  chin  and  occiput;  it  models  itself  sullicientK 
if  each  turn  of  bandage  in  meridian  and  equator  has  been  ^vell 
applied  (fig.  287);  nevertheless,  it  is  much  better  to  model  the 
jaw  b\  passing  the  hand  liorizontally  under  the  chin,  in  order 
that  the  plaster  may  make  there  a  plateau  rather  than  a  funnel. 
^  ou   then  A>ait  until   the  plaster 

sets.  "^'"    ~~      ■-■'-•'         .■.^.-  •-™.^-.-    r  : 

After\\ards  you  relieve  the 
tension  by  removing  the  loops  of 
the  girth  from  the  bar.  At  the 
end  of  ten  minutes,  lay  the  child 
down,  placing  the  head  a  little 
beyond  the  end  of  the  table,  so 
as  not  to  break  the  apparatus. 

Trimming.  —  Take  away 
(with  a  good  knife),  proceeding 
sloAvly,  all  the  part  of  the  plaster 
which  is  above  the  occipito-mental 
circumference.  This  allows  of 
the  withdrawal  of  the  girth;  to 
do  this,  take  away  the  two  sub- 
auricular  pins  and  pull  out  care- 
fully the  chin  portion  first,  then 
the  other;  or,  better,  cut  with 
the  scissors,  on  one  side  only, 
below   the   ears,    the  two    tails, 

anterior  and  posterior,  of  the  girth,  and  pull  it  tOAvards  you 
from  the  other  side  (fig.  288).  It  is  much  better  to  remove  the 
girth  than   to  leave  it  in  position. 

At  the  lower  end,  the  large  plaster  is  trimmed  in  the  same 
way  as  the  medium.  A  prov-isional  opening  is  made  afterwards 
(fig.  289)  through  which  you  Avithdraw  the  wool,  as  in  the 
medium  corset. 

Three  days  afterwards,  make  a  permanent  opening,  com- 


Fig.  290.  —  The  lar^^e  apparatus  llnished, 
with  its  opening,  reaching  up  to  the 
liYoid  bone. 


3l2        THE    CO>"STRUCTION    OF    A  PLASTER   O    PARALYSED   SUBJECTS 

mencing   at  the   junction    of  the    neck   and  the  jaw  ;  the 

larynx  being  free  in  front,  Avill  not  then  suffer  by  compression 
which  you  may  have  to  exert  over  the  affected  cervical  vertebrae 
(fig.  279).  Dorsal  compression  is  effected  in  the  same  way  as 
in  the  medium  apparatus. 

The  construction  of  a  plaster  in  paralysed  subjects. 

I  have  said  that,    not   only  Pott's  disease  of  the   superior 
regions,  but  also  all  the  cases  of  Pott's  disease  with  paralysis, 


^'"- 


Fig.  291.  —  Extension  of  the  spine  in  the  horizontal  position.  An  assistant  models 
the  apparatus  about  the  pelvis.  T-\vo  others  make  extension  and  counter-extension 
at  the  head  and  the  feet,  of  from   10  to  i5  kilograms. 


are  treated  by  the  large  plaster.  Thanks  to  its  funnel  or 
plateau  the  extension  of  the  spine  necessary  for  the  cure 
of  the  paralysis  can  be  better  and  more  exactly  preserved  than 
with  the  medium  plaster. 

The  patient  places  himself  in  the  degree  of  extension  desired 
(v.  fig.  246,  p.  27S)  for,  being  unable  to  support  himself  on 
his  feet  (on  account  of  his  paralysis),  but  only  and  very  imper- 
fectly on  the  seat,  he  ^is  somewhat  suspended  by  the  girth. 
If  (the  plaster  being  rather  slow  in  drying)  the  extension 
becomes  too  painful  towards  the  end  of  the  sitting,  you 
relieve  him  by  discontinuing  the  vertical  position. 

You  remove  him,  (at  the  same  time  as  the  bar)  and  lay  him 
down.      Then   draw  on  the  head,  by  means  of  the    bar,  with 


pott's  DISE.VSE.  TECHNIQUE  OF  THE  PLASTER  CORSET   3l3 

both  hands,  with  what  lorce  you  wish  (lo  to  i5  kilogrammes 
goiierallv),  whilst  an  assistant  holds  liim  by  the  feet  (fig.  291). 
The  apparatus  is  modelled  over  the  pelvis  as  in  hip-disease 
(v.  p.   430).      Thon  wait  in  this  position  for  the  plaster  to  set. 

///.  —   The  small  apparatus. 

The  small  apparatus  is  made  in  the  same  manner  as  the 
medium,  but  without  the  cravat  and  the  neck  piece.  It  is  an 
apparatus  for  convalescence  in  Pott's  disease  of  the  lower  ver- 
tebra. But  in  truth,  we  use  it  very  little  even  in  convalescence. 
Generally,  we  make  a  medium  plaster  Avith  a  collar  pieced 

Attention  required  after  the  application  of  a  plaster. 

A^e  have  spoken  of  the  trimming  of  the  apparatus,  of  the 
openings,  and  of  dorsal  compression. 

Sometimes  patients  (especially  adults)  are  a  little  distressed 
for  the  first  two  days.  You  may  calm-  them  by  the  mere  admin- 
istration of  anodynes,  for,  to  this  discomfort  Avill  soon  succeed 
perfect  comfort. 

You  will  leave  the  patient  afterwards  to  the  care  of  the  parents ; 

I.  Some  remarks  on  the  plaster  corsets. 

a.  In  cases  of  abscess  or  oljistiila,  make  an  opening  in  the  plaster. 

b.  Sloughing  (strictly  speaking  possible)  :  v.  p.  35i,  the  method  of 
recognising  and  curing  it. 

c.  Is  the  age  of  the  patient  AvIth  Pott's  disease,  a  contra-indication  in  the 
use  of  plaster?  —  No,  one  mav  plaster  infants  of  one  year  (taking  care  to 
prevent  soiling)  just  as  aged  people  of  more  than  5o  years. 

d.  One  may  use  chloroform  (^exccptionalh  )  when  constructing  the  plaster 
(v.  p.  35 1). 

e.  Multiple  fislulce  or  very  intolerant  and  eczematous  skins  necessitate 
daily  attention ;  in  such  cases,  one  may  convert  the  immovable  corset  into  a 
movable  one.  (v.  p.  35o). 

2.  If  the  discomfort  is  too  great,  you  may  relieve  it  by  dividing  the 
corset  in  front  in  the  median  line  so  as  to  separate  the  edges  by  i,  2  or  3  c.  m. 
—  but  bring  them  together  again  and  rejoin  them  tno  or  three  days  later, 
when  the  patient  has  become  accustomed  to  the  apparatus. 


3l4  pott's    disease.     REMOVING    AND    CHANGING   THE    PLASTER 

the  doctor  has  no  need  to  see  him  again  more  than  once  a 
month  to  attend  to  the  dorsal  compression  Avliich  is 
increased  on  each  occasion  hy  about  i/4  of  its  amount. 

Removal  of  the  plaster  towards  the  fourth  month. 

To  remove  the  apparatus.  —  Place  the  child  in  an  ordi- 
nary hath  for  a  quarter  of  an  hour.  The  plaster  softens,  and 
can  be  cut  in  a  minute  or  two,  ^Yilh  any  kind  of  knife. 

The  toilet  of  the  skin.  —  One  makes  it  with  ether  or  Avith 
eau-de-cologne,  if  the  skin  is  neither  soiled  nor  scaly.  —  In 
the  ordinary  case,  one  rubs  gently  with  vaseline  for  a  few 
minutes,  Avhich  has  the  elTect  of  softening  the  epidermic  scales; 
after  Avhicli  one  dries  the  skin  with  a  piece  of  fine  linen,  very 
gently,  and  passes  over  it  a  little  alcohol  or  eau-de-cologne.  One 
cleanses  the  front,  then  the  back,  turning  the  patient  over. 

Search  for  abscess.  —  You  look,  by  examining  the  back 
and  the  iliac  fossae,  or,  as  the  case  may  be,  the  neck  and  the 
pharynx,  for  any  trace  of  abscess  in  formation. 

THE  CONTINUATION   OF  THE  TREATMENT  IN  POTT'S  DISEASE 
AND   ITS  DURATION 

Placing  the  patient  on  his  feet. 

If  no  abscess  supervene,  everything  is  reduced  to  making  a 
new  plaster  every  [\  or  5  months. 

After  two  year's  rest  in  the  recumbent  position,  the 
patient  is  placed  on  his  feet,  provided  that  he  is  not  suffering 
any  pain,  either  spontaneously,  or  by  pressure  on  the  back, 
and  that  his  general  condition  is  so  good  as  to  allow  you  to 
think  that  the  vertebral  focus  is  extinct  (or  almost  so). 

CONVALESCENCE 
The  apparatus. 

Then  the  patient  is  allowed  to  get  up,  wearing  the 
same  plaster  apparatus.  —  Hospital  cases  keep  the  plaster 


CONVALESCENCE    IN    POTT  S    HISEVSE 


.Sl5 


on    ("or    :>,   or   3    years   lonf^cr 
as  a  miiiiimini  from  this  time. 
■^  ^  1 1   must  be   removed  only 

^^  -*K  when,  lor  the  last2  or  3  years, 
at  least,  pressure  over  the 
verlebne  no  longer  elicits 
the  least  tenderness,  and  the 
line  of  the  back  has  not  va- 
ried one  millimetre,  provided 
that  the  general  condition  of 
tiie  patient  is  perfect.  Under 
lliese  conditions  the  welding  o( 


Fig.  292.  — ^tedium  celluloid 
apparatus.  Oae  sees  the 
anterior  part  of  the  dorsal 
shutter. 

the  s^lne  may  be  sup- 
posed to  be  complele 
and.de/inite.  This  can 
be  ascertained  by  a  ra- 
diogram of  the  profile 
whenever  practically 
possible. 

In  the  case  of  town 
children,  it  is  advan- 
tageous, when  putting  them  on  their  feet,  to  replace  the  plaster 
bv  removable  corsets,  Avhich  allow  of  a  thorough  toilet,  are  lighter 


Fig.  393.   —  Large  celluloid  apparatus 
for  Pott's  disease,  cervical  or  cervico-dorsal. 


3i6 


POTT  S    DISEASE.    CORSET    IN    CELLULOID 


Fig.   29/1.   —  Celluloid  apparatus  with  large  collar,  view  of  posterior  aspect. 


Fig.   295.  —  An  arrangemsQt  for  fixing  the  chin  piece  of  the  minerva. 


POTT  S    DISEASE. 


COUSET    1>    Cl-I.LLLOll) 


than  the  plasler,  and  furnislied.  like  it.  \villi  a  dorsal  opening 
and  a  shutter,  which  allow  of  continuance  of  the  support  and 
of  the  compression  of  the  affected  vertebra;  (fig.  292  and  29'^). 


Fig.  296.  —  Tte  patient  may  be  dressed  in  a  jersey,  —  two  lathes  underneath  the  jersey. 


<(  Orthopoedic  »  corsets. 

The  best  from  all  points  of  view,  are  the  corsets  in  celluloid 
(v.  fig.  292  to  294)- 

It  is  better  as  I  have  said,  to  leave  the  rather  difficult 
construction  of  these  apparatus  to  special  workers,  and  so,  all 
that  is  left  for  you  to  do  is  to  make  a  mould  and  fit  the  apparatus 


3i8 


POTT  S    DISEASE. 


CORSET    I>'    CELLULOID 


on.     This,  each  of  you  Avill  be  able  to  do  quite  easily  after 
having  read  that  which  follows  : 


Fig.  297.   —  Placing  in  position  the  zinc   laths  which  will  serve  as  a  protection  when 
cutting  the  plaster. 

Method  of  taking  a  mould  of  the  trunk.    —  The  patient 
dressed  in  a  jersey   with    laths  of  zinc  in  position  (fig.  296), 


TECHNIQUE   OF    Mol  I.HINC.    THK    TRLNK 


6l(Y 


is  supporleJ  by  ini>aiis  of  llic  yirlli;  but  be  careful  liere  to 
j^uard  against  u  stretching  »  the  patient  until  his  heels  lose 
touch  Avilh  the  floor;  the  tension  should  be  much  less,  say 
almost   nil.  if  von  wish  In  have  an  apparatus  in  Cflluloid  fitting 


Fig.  298.  • — •  Application  of  the  posterior  attelle. 


very  precisely.  Instead  of  commencing  the  moulding  by 
means  of  strips,  —  as  was  done  for  the  ordinary  plastered 
corset,  begin  by  applying  the  attelles.  The  dorsal  attelle  is 
placed  in  position  first  (fig.  298);  in  order  that  its  edges  adapt 


320 


POTT  S    DISEASE. 


CORSET   IN    CELLULOID 


themselves  better  over  the  sides  of  the  trunk,  make,  if  need  be, 
several  notches  in  it.  The  anterior  attelle  and  the  cravat  are 
applied  in  the    same  way    as  is  done    in  the  construction    of 


Fig.  299.  —  The  two  attelles  are  in  position  ;  flatten  them  out  carefully  over  the  skin. 

the  ordinary  plaster  apparatus.  Roll  one  or  two  strips  over 
the  attelles  and  between  each  layer  of  these  spread  a  coating  of 
plaster  cream  (fig.  3oo). 


Ml'.riKil)    III'     I  \M\(;     A     MOI  1,1)   OF    TIIK    TUUNK 


'A  21 


Tliis  will  sirongllien  your  nKnild.      This  dono,  verify  and  roc- 
iHn.  if  iioccssary,  lliG  posture  of  the  pal  ion  I.      ^  Ou  musl,iasll\ , 


Fig    3oo.   —  The  attelles  are  held  in  position   and  adapted   by  a  plastered  strip. 

whilst  the  drying  is  proceeding,  model  the  contours  of  the 
pelvis,  and  to  do  that,  your  hand  must  embrace  very  exactly 
the  iliac  crests,  as  has  been  described  in  the  construction  ol 
the  plaster  corset. 

Calot.   —  Indispensable  orthopedics.  21 


322 


POTT  S    DISEASE.    COUSET   l.\   CELLULOID 


When  the  apparatus  is  dry,  thai  is  to  say  at  the  end  of  from 
5  to  lo  minutes,  you  cut  it  with  a  knife,  following  the  zinc 
laths.     After  it  is  cut  it  is  easy  to  withdraw   the  laths  and  to 


Fig,    3oi.  —   You  divide    ihe  mould  upon  the  zinc   strips  by  means  of  a  knife  or  a 

shoe-maker's  tool. 


open  the    apparatus  sufficiently  to  allow  of  it's  being  removed 
(fig.  002  and  3o3). 

When    the    moulding   is    completed,    you  carefully  bring 


Ti:ciiMorr  oi-   moulding  tiiiv  trunk 


:wi 


togcllior'    the  sides  of  llic  scclidii   and    keep   lliciii   in   a|i|io-.ll  ion 
eillifi'   h\    eiiclosiny-  llie  avIioIc   a|)|)aialns  with  seNcial    luiiis   of 


/^  fi^^ 


\    \ 


w  \ 


Fig-   3o2.  —  The  laths  liave  been  removed;    you  commence  to  disengage  the  moukl 
from  the  right  side  of  the  patient. 

soft  muslin  bandage  (fig.  oo'\),  or  by  applying  a  narrow  plas- 
tered strip  over  the  slit,  covering  the  two  edges. 

In  this  case,  it  is  necessary  to  keep  the  edges  in  contact 
until  the  ])lastered  strip  is  dry.  By  this  method  the  form  of 
the  trunk  will  bo  reproduced  verv  exactly. 


32/, 


POTT  S   DISEASE.    CORSET   O    CELLULOID 


For  greater  security,  you  might  —  as  we  have  already 
indicated  —  pack  the  interior  of  the  mould  with  paper  or  with 
wood  shavings.     The  mould   Avill  take  2 4  hours  to  dry  coin- 


Fig.  3o3.  —  The  mould  is  taken  off  as  you  would  take  off  a  ^Yaist-coat. 


pletely;  during  that  time,  you  will  hang  it  up,  or  at  least  you 
will  support  it  upright,  for  should  it  rest  on  one  of  its  faces,  it 
will  run  the  risk  of  flattening  and  becoming  out  of  shape. 


ruiAI.    OF    THE    CELr.LI.OII)   CORSET 


:w. 


MoulilliKI  (I  ci'l/ii/diil  Willi  <i  lartje  col/ai'.  —  \  ou  proceed  in 
the  same  \\a\  w  licii  it  is  necessary  to  mould  also  the  hasc  ol' 
the  skull  (lor  Poll's  disease  in  llic  cervical  region);  the  only 
dillereiice  is  that  you  complete  the  top  part  of  the  jersey  by  2 
or  3  turns  of  soft  muslin  bandage,  going  from  the  chin  to  the 
vertex  and  from  the  occiput  to  the  forehead,  so  as  to  avoid  the 
application  ofplasterupon  the  hair;  let  the  zinc  strips  risehigher, 


Fig.  3oi .  The  edges  of  the  mould  are  brought  together  by  means  of  a  bandage  of 

soft  muslin. 

the  anterior  up  to  the  point  of  the  chin,  the  lateral  up  to  above  the 
mastoid  region  (fig.  3o5  and  3o6) .  While  the  apparatus  is  drying, 
you  model  the  chin  with  one  hand,  the  occiput  with  the  other. 

Method  of  fitting  a  cellaloid  corset.  —  The  orthopedic 
apparatus  maker  brings  you  the  corset,  divided  through  the 
median  line  and  over  the  two  shoulders,  so  that  you  may  try 
it  on  (fig.  307,  3o8  and  309).  We  have  mentioned,  in  the 
generalities  (v.  p.  io3),  the  utility  of  this  trial. 

Introduce  the  patient  sideways  into  the  corset,  so  as  not  to 
have  to  open  the  apparatus  too  much  (fig.  307). 

The  corset  is  fastened,  and  the  sides  are  approximated  by 


32() 


POTT  S    DISEASE. 


THE    MINERVA 


IN    CELLULOID 


means  of  three  leather  straps  encirchng  the  trunk  —  one  helow 
the  axillae,  the  other  at  the  Avaist,  and  the  last  at  the  level  of 
the  pelvis  —  whilst  an  assistant  supports  the  apparatus  above 
the  shoulders.  The  straps  are  tightened  so  as  to  ensure  the 
perfect  application  of  the  apparatus  to  the  body ;  if  the  appa- 
ratus is  too  large,    you  let    it's  edges  overlap,  and  you  mark 


Fig.  3o5.  Fig.  3o6. 

Fig.   ,3o5  and  3o6.  —   The  method   of  procedure  for   moulding  the   cervical  part,  or 

the   minerva. 


with  chalk,  on  the  celluloid  itself,  the  corrections  to  be  carried 
out.  Note  also,  the  height  to  be  given  to  the  collar,  the  hol- 
lowing to  be  made  at  the  shoulders,  the  openings  required, 
either  in  front  or  behind. 

As  the  patient  wishes  to  be  able  to  rest  in  a  sitting  posture, 
you  mark  the  point  where  the  apparatus    should  stop  behind. 


Mom:  Aiioi  1   Tin:   coiuuccikjn  ov   <;iiii!(.)SiTii:s 


327 


Iq  llic  same  wun  ,  lo  allow  ut  llc.viuii  ol  liic  lliiglis,  ndu  nole  the 
height  of  the  hollowings  to  be  made,  so  that  flexion  of  the  thighs 
may  have  an  amplitude  of  80"  at  least. 

To  li'Y  on  a  minerva,  mark  out  the  occipito-meutal  line, 
indicating  where  the  hollow  has  to  be  for  the  ears,  and  verify 
the  curve  of  the  nucha  and  of  iho  neck. 


Fig.  307.  —  Trial  of  a  celluloid  corset. 
—  First  slage  of  putting  on  the  corset. 


Fig.    3o8.    —     Second    stage    of 
putting  on  the  corset  for  trial. 


Before  finishing  with  the  orthopoedie  treatment 

ONE  WORD  MORE 

ON  THE  CORRECTION  OF  GIBBOSITIES. 

The  correction  of  the  gibbosity,  that  must  be  our  aim. 

Indeed,  according  as  Ave  overcome  the  gibbosity  or  not,  Polt's 
disease  avUI  cease  to  exist,  or  will  remain  the  terrible  malady 
that  we  know  it  to  be. 

a.  Gibbosities  small  and  medium. 

What  vou  must   know  is  how  to  correct  gibbosities  at  the 
stage    thev  are  in  when    presented  to    you    for   the  first  time. 


328       pott's   disease.     EVERY    PRACTITIONER   :\IAY    BE   ABLE 


Fig.  Sog.  —  Trial  of  the  celluloid    continuetl).      Tracing 
with  black  chalk   the  crossing  points. 

Even  in  ihe  Avorking-  class,  children  will  be   brought  to  you 


Fig.  3 10.  —  Celluloid  corset. 
Without  collar  :  front  view. 


Fig.  3ii.  —  The  same  seen  from  behind, 
its  dorsal  opening  closed. 


shortly^ after  'the  gibbosity  has  become  apparent  (and   it  is 


TO   CORRECT   SMALL    AM)   RECENT    GIBBOSITIES  33(J 

very    evident   to  everybody  when  there   is  a  destruction 
equal  to  half  ov  two  lliiids  dI"  a  vertebra). 


Fio-.    3i2.   —  The  method  of  making  dorsal  compression  with  a  celluloid  apparatus. 
The  Avindow  open  for  the  introduction  of  cotton  -wool  scjuares. 

Seeing  that,  at  this  moment,   you   can    still  hope  for 


Fig.  3i3.  —  The  cotton  wool  squares,  larger  than  the  window  and  one  centimetre 
in  thickness,  are  introduced  one  hy  one,  between  the  gibbosity  and  the  sides  ol 
the  opening. 

the  best  by  harmless  and  easy  methods,  we  say  that  the 
problem    of    the  treatment  of   Pott's    disease   is  resolved 


33o    pott's  disease. 


SMALL   GIBBOSITIES   MUST    BE    TREATED 


from  the  practical  point  of  view,  —  in  the  same   way  as  it  is 
resolved  for  congenital  dislocation  of  the  hip,  since,  in  children  2, 


Fig.   3 1 4.  —  One  introduces  thus  from  8  to    lo   of  these   pads  of  wool,   which  form 
a  prominence,  the  highest  point  of  which  is  at  the  centre. 

3,  4  years  of  age,  we  are  able  to  cure  it,  although  we  may  no 


Fig.   3i5.  —  Flaps  of  the  opening  closed   down  over  the  avooI.     It  is  locked  with  a 
little  key  ad  hoc.  —  This  is  the  corset  as  it  is  worn. 

longer  be  able  to  do   so   when  the  patient  has  passed  a  certain 
age. 

We  have  seen  that  there  are  two  methods  of  treating  gibbo- 


DLUATION    01'    Tilt:    THEATMENT    OF    A    (ill'.IU  ISII V  33l 

sities ;  extension  and  direct  pressure;  I  recommend 
especially  the  last,  because  extension  is  much  more  trau- 
matising  and  more  difficult  lo  carry  out.  It  is  also  less 
efficient  and  less  certain,  il  being  impossible  to  keep  it  up 
thoroughly  by  means  of  liie  apparatus  without  injuring  the 
patient  at  the  chin.  On  the  other  hand,  direct  pressure  is 
gentle,  well  tolerated,  easy  to  carry  out  and  to  keep  up,  and 
very  effective.  Rely  then  on  direct  pressure  only,  making  no 
other  extension  but  that  which  can  be  made  without  the 
heels  leaving  the  ground.  In  the  second  place  you  have  seen 
that  the  correction  is  made  in  lo  or  i5  sittings,  and  not  in 
one.  Correction  by  stages  is  gentler,  more  harmless  and  quite 
as  effective.  ]No  time  is  wasted,  seeing  that  the  correction 
once  obtained  has,  in  both  cases,  to  be  maintained  until  the 
tuberculosis  is  cured  and  ankylosis  produced,  which  requires 
several  years.  Therefore,  nothing  is  to  be  gained  by  redressing 
at  one  sitting. 

\\  e  have  said  that  the  compression  must  be  renewed  every 
month,  until  the  gibbosity  is  effaced  and  the  Pott's  disease 
cured. 

Duration  of  treatment  of  a  Gibbosity. 

A.  small  or  medium  gibbosity  in  Pott's  disease  in  progress 
may  be  effaced  in  from  6  to  12  months;  this  will  depend  upon 
the  degree  of  the  compression. 

But  the  cure  of  Pott's  disease,  the  anterior  welding,  is 
hardly  ever  secured  before  3  or  4  years,  —  sometimes  sooner, 
often  later.  It  depends  upon  the  general  treatment  and  the 
gravity  of  the  tuberculosis. 

At  any  rate,  one  ought  not  to  discontinue  compression  until 
the  "welding  is  complete  and,  even,  has  been  completed  for  i  or 
2  years. 

What  is  the  criterion  of  the  anterior  welding? 

The  problem  is  the  same,  here,  as  after  correction  of  a 
deformity  in  hip-disease  or  of  white  swelling  of  the  knee.     As 


332 


TREATMENT    OF   POTT  S   DISEASE 


an  absolute  criterion  there  is  nothing  except  the  X  rays,  which 
shews  the  formation  of  the  anterior  callus  (v.  fig.  229).  B:!t 
it   is   difficult    to    obtain    clear     images    of    the   profile,    and 


Fig.  3i6.  - —  Double  gibLosily.  —  In  sucli  u  case  a  single  opening  is  made  corres- 
ponding to  the  two  gibbosities  and  to  the  intervening  segment,  and  compression 
is  applied  by  means  of  three  large  pads  (of  which  the  dimensions  exceed,  as  usual, 
those  of  the  opening  in  the  plaster). 

moreover  the  great  majority  of  practitioners  have  not  a  radio- 
graphic installation  at  their  disposal. 

In  default  of  the  X  rays,  there  is  the  clinical  criterion 
indicated  before,  namely,  perfect  general  condition,  strict 
local  treatment  which  has  been  continued  already  three 
or  four  years,  absence  of  pain  on  pressure,   a  rigid  back 


XMiM    i<>   i>i>  l^    >i"^  (^^^^   "I"  '"'"  f'i"«'»^l'l"iES 


333 


shewing  no   signs    of   having  bulged,    not   even     by    one 
millimetre,  for    more  than  a  year. 

Rcmcnibci-  lli.il  il  is  b.Htcr  to  err  by  excess  ralhcr  ll.an  by 
dclaultol-piccaulioas;  c.Mitlnue  ihcuseofthe  apparatus  two  years 
too  Ion-  rather  than  disconthmc  its  use  two  months  too  soon. 

\ucl  then,  when  it  is  taken  off,  it  must  be  taken  off  onl.N 
te.nporarilN.  for  a  dav  or  two  at  the  commencement;  tlierefore 
look  at  the  patient  pretty  often,  and  at  the  hrst  sign,  that  is  Jo 
say  at  the  first  pain  or  slight  visible  flexion  of  the  back, 
replace  the  apparatus  for  a  fresh  period  of  two  years. 

6.  Old  Gibbosities. 

I    have    not  advised  practitioners  who    are   not    specialists 
to  undertake   in    a  general  way  the  treatment  of  extensive  and 
old  gibbosities,    and  have  explained   why.      It  does  not  follow 
that    a    specialist  can   do  everything   in   these  cases.      He  will 
succeed  (but  at  the  price  of  what  efforts!)  in  effacing,  m course 
of  time,  2/3  or  3/4  of  the  gibbosity,  even  when  it  isankylosed. 
We  know     in  fact,  that  ankylosis  is  never  complete  before   a 
number  of  vears.      On  the  other  hand,  experience  allows  us  to 
aflirm  that  it  is  possible, even  when  ankylosis  is  complete, 
to  modify,  in  3,  4,  or  5  years,  the  shape  of  the  osseous  block, 
provided  that  the  patient  is  a  child  whose  grow  th  has  not  ceased. 
In  fact,  the  osseous  block  undergoing   from  the  fact  of  our 
treatment,  a   continuous  pressure  behind  and    a  relaxation    m 
front     will  finish  by  becoming  atrophied   behmd  and  hyper- 
trophied  in  front.     We  are  able  thus,  in  avery  notable  degree, 
to  regulate  and  direct  its  development,  to  steer  it  in  a  direcl^ion 
opposite  to  that  it  would  have  followed  if  it  had  been  left  to 
itself      For  cases  of  verv  large  and  old  gibbosities,  one  can  say  m 
all  truth  that  the  mare  the  treatment  is  prolonged,  up  to  the 
end  of  the  growth  of  the  patient,  the  nearer  it  will  approach 
perfection,   without  of    course    reaching    it.      Ihe    length   of 
treatment  here  depends  then  upon  the  result  we  are  striving  for. 
In  subjects  who  have  arrived  at  the  eal  of  their  growth    - 


334 


POTT  S   DISEASE   WITH    ABSCESS 


when  the  gibbosity  has  become  welded  —  there  is  nothing  to  look 
for  in  correction;  one  would  gain  nothing  or  next  to  nothing. 

B.  —  TECHNIQUE  OF  THE  TREATMENT  OF  ABSCESS 

An    abscess    exists  ;  you  know   where  and  how  to  find  it. 
I  have   mentioned  in  what  case  to  abstain  from  interfering 


H.F 


Fig.   317.  —   e.  i.  anterior   iliac  spine.    —   e.  p.  pubic  spine.  —  P.  point  of  election 

for  puncture. 

with,  and  in  what  case  one  ought  to  treat,  an  abscess.  To  treat 
it  does  not  mean  to  open  it;  that,  never !  It  is  especially 
when  it  is  a  question  of  abscess  due  to  Pott's  disease  that  it  is 
not  advisable  to  open  it  nor  allow  it  to  open,  because  here, 
more  than  anywhere  else,  to  open  it  may  mean,  and  most  often 
will  mean,  death. 


ESPFCIAM.V    NEVEK    OPEN    ABSCESSES 


;^;i5 


If  Poll's  discasL'  was  so  of  leu  falal  in  funncr  limes,  il  was 
because  the  abscesses  Avere  opened.  And  if  Poll's  disease  of 
ihc   luiiib;ir    Nciicbr.r    was    considered    as    more    serious    iban 


Pio-,  3i8.  —  e.  i.  anterior  iliac  spine.  —  e.  p.   pubic  spine.  —  i   p.  pubic  sj-mphysis. 

a.    c.   crural  arch. —  c.    s.    spermatic  cord.  —    v.  bladder.    —  o.  urachus.  — 

p.  sacral  promontory.  —  i'.  ;.   iliac  vessels.  —  c.   p.  pelvic  colon.  —  c.  /.  lumbar 
colon.  A'  A'  abscess  of  wallet  shape.  —  P.  point  of  election  for  puncture. 

Pott's  disease  of  the  dorsal  vertebrte,  the  former  being  nearly 
always  fatal,  Avhilst  the  latter  was  scarcely  ever  so,  it  was 
due  onlv  to  the  fact  that  the  first  is  accompanied  by  accessible 
abscess  which  one  Avould  hasten  to  open,  whilst  the  second, 
presenting  no  perceptible  abscess,  would  escape  the  bistoury  and 
it's  disastrous  consequences. 

Therefore,  the  sovereign  dogma,  the  untouchable  dogma,  is 


336 


POTT  S    DISEASE    AVITH   ABSCESS 


never  to   open   an   abscess  in  Potls's    disease.      The    results  of 
operative  surgerv  in  such  cases  are  mainlv  disastrous.     And  of 


Fig.  3ig.  —  Abscess  by  gravitation.  —  On  the  left  side,  the  abscess  has  invaded 
a  considerable  portion  of  the  internal  iliac  fossa  ;  on  the  right  side,  the  pus  has 
followed  the  psoas  beneath  the  crural  arch  and  formed  a  sac  on  a  level  with  the 
lesser  trochanter.  The  needle  has  been  pushed  against  the  upper  edge  of  the  arch, 
into  the  pelvic  sac  of  the  abscess. 


all  operators,  the  most  brilliant,  the  most  audacious,  the  most 
intrepid,  will  be  here  the  most  dangerous. 


MO    NOT    TOUCH    DEEV    ABSCESSES 


337 


^^'llal  must  be  done  then? 

Oh  I  it  is  very  simple.  I  Itlir  abscess  remains  deep  and  not 
easily  accessible, do  nolliing,  wail.  Two  things  may  happen; 
eitiier  it  will  be  reabsorbed  spontaneously,  oril  will  grow  larger 


Fi^.  320.  —  Two  abscesses  of  wallet  form.  On  the  right  the  abscess  is  gripped 
under  the  arch  and  is  pointing  at  the  inner  aspect  of  the  Ihigh ;  on  the  left,  it  has 
passed  through  the  great  sciatic  foramen  and  found  its  ^YaY  into  the  fossa.  To 
puncture  at  S  S'  would  not  always  be  sufficient:  it  would  be  necessary  to  punc- 
ture also  at  P,  on  the  right  side,  close  to  the  arch.  On  the  left,  treat  the  sac 
S'  and  compress  it:  if  the  pelvic  sac  is  not  cured,  the  pus  will  collect  gradually  in 
the  internal  iliac  fossa  where  vou  will  be  able  to  attack  it  in  course  of  time. 


and  become  accessible.  From  this  moment,  and  without  Avaiting 
for  it  to  involve  the  skin,  treat  it  by  puncture  and  injection. 

I  have  only  a  word  to  add  a  propos  of  the  peculiarities 
which  abscesses  in  Pott's  disease  present. 

I"     The  abscess  in  Pott's  disease  may,  strictly  speaking,  be 

Calot.  —  Indispensable  orthopedics.  32 


338 


POTT  S    DISEASE   AYITH    ABSCESS 


infected  from  the  beginning,  independently  of  any  surgical  inter- 
ference, small  or  great,  independently  of  any  fissure  in  the  skin. 
The  infection  then  comes  from  Avithin,  from  the  contiguity  of 
the  intestine  (fissured  or  not).      But  be  not  afraid  for  you  will 


Fig.  32  1.  —  Puncture  of  an  iliac  abscess,  through  an  opening  made  in  the  plaster 
apparatus,  —  one  will  push  aside  the  flaps  of  jersey,  and  carefully  protect  with 
compresses  of  sterilized  gauze,  the  edges  of  the  opening,  as  was  represented  in 
figs  III.   122  and  i2/|.     (chap.  IIIJ. 


scarcely  ever  see  this,  as  personally,  I  have  seen  it  but  6  times 
in  20  years. 

Signs  of  infection  :  Evening  fever  with  marked  morning 
remissions ;  the  contents  of  the  abscess  becoming  sanguinolent, 
of  the  colour  of  tomato,  or  of  wine  lees. 

Try  to  reduce  the  temperature  by  punctures  without  conse- 
cutive injections.  I  succeeded  once,  and  in  five  other  cases, 
to   overcome   the   fever,   I   was  obliged,    after    some   time,    to 


1)0   NOT    PLNCTLKE    L  .NLK>S    TIIi:    ABSCESS    IS    EASILY    ACCESSIBLi:       33(» 

opcii  the  ahscess.  Indeed,  tliis  opening  nuut  nol  be  delaNed 
too  long  as  llie  viscera  iniglil.  in  course  of  lime,  become  irre- 
mediably infected.  Therefore,  when  I  lie  fever  has  persisted  for 
1 3  days,  and  you  are  certain  it  is  not  attributable  to  any  inter- 
current malady,  do  nol  wait,  open  and  drain  the  abscess. 
Then  Iroal  a<  for  infected  li<tul;r. 


Fig.  822.  —  Abscess  in  the  form  of  a  mushroom  or  wallet  which  has  perforated  the 
deep  layers  of  the  abdominal  wall  and  is  spreading  under  the  skin:  in  this  case,  it 
would  be  better  to  puncture  the  principal  sac,  as  indicated  by  the  dotted  line  P. 

2'""-  Take  care,  in  the  abdominal  abscess  of  Pott's  disease 
not  to  inject  diffusible  liquid,  producing  loo  great  a  tension  (iodo- 
formed  ether,  oxygenated  water).  In  spite  of  the  fact  that  these 
very  diffusible  liquids  may  appear  a  y:(770/7'  preferable  here,  in  thai 
they  would  more  certainly  attack  the  affected  points,  they  are  to  be 
avoided,  because  they  might  penetrate  by  breaking  through  into 
a  visceral  cavity,  especiallv  when  its  wall  is  altered  and  attenuated. 


Sl\o     pott's  disease. 


ABSCESS   >"EAR    TO    BLOOD    VESSELS 


o'^diy  \Yhen  an  abscess  presents  a  principal  sac  and  several 
diverticula,  puncture  the  sac  or  diverticulum  which  is  most  acces- 
sible, making  sure  that  you  empty  the  entire  abscess.  If  not, 
make  punctures  and  injections  into  the  large  cavity  as  Avell  as 
into  the  diverticula. 

Peculiarities  of  Technique  according  to  the  seat  of  the  abscess. 

A.      The  abscess  is  situated  near  to  blood-vessels. 

At  the  fold  of  the  groin,  or  in  the  cervical  region  (fig.  107 
to  lAo,  p.  i/ig). 


Fig.  828 .  —  On  the  right,  a  large  abscess  has  invaded  the  whole  of  the  iliac  fossa  and 
pushed  inwards  the  intestinal  mass  so  that  there  is  no  risk  of  wounding  it  by 
puncture.  On  the  left  the  needle  P.  has  been  pushed  in,  close  by  the  iliac 
spine ;  its  point  travels,  grazing  the  bone  (following  the  dotted  line),  into  the  puru- 
lent collection. 


B.     Abscess  of  the   iliac  fossa.  —  You  will  generally 
interfere  only  in  the  case  of  very  ^superficial  bulky  abscess,  that 


'2'".    ir.l.VC    VHSCESSP.S 


34 1 


is  one  ill  wliicli    \i)u  can   introilucc  llie  needle   williouL  having 


Fig.  324-  —  Abscess  in  Petit's  Iriaagle  (ligured  on  (he  left  by  cross-liatchins;). 

anything  to  fear  —  I  might  even  say  anything  to  avoid. 

But  it  may  happen  that  one   is  unwilhng  to  wait T  for  the 
collection  coming  so  near  the  skin,  because  that  requires  some- 


Y<A\A^      <iu. 


.evteti'.-x^ 


l^^u.-5cfeJ    y>\ivvck&[ixoij.fi. 


))  co-i  ■  c\A\\. 

Fig.   325.    —   A.     Abscess   of  vertebral   origin  siluate.l    behind   the    periosteur 
B.     Glandular  abscess  situated  in  front  of  the  periosteum. 


342 


POTT  S   DISEASE.    2"".     ILIAC   ABSCESSES 


times  one  or  several  years.  It  is  allowable  to  expedite 
matters  provided  however  that  the  ahscess  is  ah'eady  suffi- 
ciently large  —  as  large  as  the  closed  fist,  for  example,  —  and 


»i<tii.. 


Fig.  326.  —  In  order  to  puncture  relro-pharyngeal  abscesses,  one  marks  out  a  line 
over  the  t^ansver^e  apophyses.  —  The  line  of  the  apophyses  of  the  first  four  cer- 
vical vertebrae  is  found  to  coincide  with  a  vertical  line  running  down  from  the 
external  auditory  meatus.     One  finger  will  push  the  sternomastoid  muscle  forwards. 


undoubtedly  in  the  iliac  fossa.  Do  not  forget  that  these 
collections  are  seated  at  the  commencement  in  the  very  sheath 
of  the  psoas. 

To  reach  the  abscess  before  it  has  come  near  the  surface  of 
the  skin  you  conduct  your  needle  immediately  above  the 
crural  arch  and  push  it  in,  not  directly  from  front  to  back, 
but  upwards,  at  an  angle  of  20°  or  25^  (fig.  323). 

You  will  feel  when  you  arrive  in  the  sheet  of  liquid. 


3"".     HETUO-IAMltAK    AKSCESSES 


3A3 


C.  Retro-lumbar  abscesses  (y.  lig.  .)<'i). 

■y\\o  Wrliiiiquc  here  docs  not  present  anv  dillicnltics. 

D.  Retro-pharyngeal  abscesses  (lig.  '6:io). 

To   open   Ihese  abscesses,   as    is   done  nnlbrlunalely   nearly 


^l.Mast 


Fi.  3>-  -  Puncture  of  a  retro-pharvngeal  abscess  occurring  m  the  body  of  he 
'third  cervical  vertebra  and  not  manifesting  itself  by  any  clinical  sign  m  the 
lateral  parts  of  the  neck.  -  M.  Inferior  maxilla.  -  L.  Tongue.  —  ^  ^ ^^- 
tebra.  -  p.  v.  n.  carotid  sheath.  -  The  needle  is  pushed  in  front  of  the 
transverse  process,  it  grazes  the  bone,  taking  first  the  direction  i,  then  the  direc- 
tion  3. 

everywhere,  is  nearly  always  fatal,  death  being  due  to 
infection. 

Do  not  touch  them,  unless  your  hand  is  forced  by  acci- 
dents of  disphagia  or  asphyxia  —  in  which  case  you  should  not 
open  the  abscess,  but  you  should  puncture  it. 

You  puncture  it  through  the  lateral  parts  of  the  neck, 
even  when  the  abscess  is  not   perceptible  there. 


344     pott's  disease.  —  4™-  retro-pharyngeal  abscesses 


Technique  of  the  puncture  of  retro-pharyngeal  Abscess. 

To  be  quite  sure  of  the  immobility  of  the  patient,  anaesthet- 
ize him  (unless  you  are  dealing  with  a  very  reasonable  adult). 
You  puncture  against  and  in  front  of  the  transverse  process 


Fig.  828.  —  To  show  the  track  the  needle  follows  :  we^have  made  on  the  cadaver  some 
dissections  of  the  region  after  the  needle  was  introduced;  one  sees  that  it  has 
penetrated  within  a  hair's  breadth  of  the  anterior  surface  of  the  vertebrae,  passing 
behind  the  prevertebral  muscles ;  the  carotid  sheath  which  was  lying  in  front  of 
the  muscles  has  been  pushed  inwards  and  forwards  to  allow  of  the  point  of  the 
needle  being  seen. 

of  the  axis,  or  of  the  3"^  vertebra,  which  one  feels  quite 
easily  (fig,  826);  the  needle  grazes  the  bone  and  remains 
consequently  well  behind  the  vessels  from  which  it  is 
separated  by  the  small  prevertebral  muscles  (longus  colli, 
rectus  capitus  anticus  and  obliquus  superior)  and  thus  arrives 
at  the  collection  (fig.  827  and  828).  Puncture,  then  inject 
oil,  creosote  and  iodoform  rather  than  naphtol,  because 
a  single  injection   of  oil  is  often  sufficient  to  cure  the  abscess 


1  uiA  I  \iK\r  in"  I'lsri  I,  i;   in   i'(>ii'>   disease  3/io 

(iinil    N.iu    will    raivl\    li;i\e    to    repeal    ihls    delicate   opeialioii ). 

Duration  of  treatment  of  an  abscess  in  Pott's  disease. 

The  cure  may  be  oblaincd  in  two  inonlhs  ;  but  il  is  iiol  neces- 
sary lo  go  so  quickly,  lake  rallier  3  or  4  months  by  making  a 
punclureevery  i5days(which  obviates  all  fatigue  lo  the  paticul). 

Will  the  abscess  return  ?  —  No.  scarcely  ever,  provided 
that  the  general  health  is  good  and  that  you  do  not  allow  the  |)a- 
tient  to  walk  about  before  6  or  8  months.  If  it  should  return. 
you  would  treat  it  in  the  same  way. 

What  is  the  effect  of  treatment  and  cure  of  the  abscess 
upon  the  treatment  and  cure  of  the  Pott's  disease?  AMien 
the  abscess  is  found  to  be  in  communication  with  all  the  affected 
vertebral  bodies,  it  is  evident  that  the  liquid  injected  into  the 
abscess  cavity  will  touch  all  the  affected  points,  penetrating  the 
tuberculous  granulations,  dissolving  them  (naphtol),  or  transfor- 
ming them  into  hard  tissue  (iodoform)  and  by  it's  repeated  and 
continuous  action,  completely  improve  the  condition  of  the 
advancing  osseous  focus  and  thus  ensure  the  cure  of  the  vertebral 
focus  itself.  It  is  certain  then  that  from  the  point  of  view  of 
duration  of  the  disease,  one  gains  something  by  having  an 
abscess  by  gravitation. 

C.  —  TREATMENT  OF  FISTUL>€  IN    POTT'S  DISEASE 

We  have  described,  page  225,  how  infected  hstulas  are  distm- 
guished  from  non-infected. 

In  the  non-infected  fistula,  make  modifying  injections  of 
creosote,  of  iodoform  and  of  camphorated  naphtol.  in  the  form 
of  liquid  or  of  paste,  —  as  Ave  have  explained  in  chap.  Ill 
(V.  p.  17G). 

In  the  infected  fistula,  on  the  contrary,  do  not  make  modi- 
fying injections,  they  w^ould  be  harmful. 

In  such  cases,  if  there  is  no  fever,  you  must  learn  to 
patiently  aAvait  the  closure  —  with,  as  the  only  treatment,  aseptic 
dressings,  rest,  over-feeding  and  a  sojourn  at  the  seaside. 


3li6  TECHNIQUE   OF    THE    TREATMENT   OF   POTt's   DISEASE 

li  the  fever  exceed  38.5°  and  persist  beyond  several  weeks, 
endeavour  to  reduce  it  by  improving  the  drainage  of  the  pus. 

But  take  care  (even  if  the  drainage  is  not  suificient)  not  to 
have  recourse  to  great  surgical  interferences,  on  the  pretence  of 
making  radical  cures,'  because  those  operations  give  twenty 
times  more  chances  of  aggravating  the  infection  and  the  fate  of 
the  patient  than  of  ameliorating  them. 

Primo  non  nocere  :  an  operation,  necessarily  incomplete 
here,  would  redouble  the  septic  absorption  and  infection. 
\^'hilst  if  you  do  not  operate,  you  leave  the  patient  with  a  chance 
of  cure.      Sometime,  indeed,  you  will  see  him  cured. 

Too  often,  we  shall  be  powerless;  the  fever  will  persist  and 
Avill,  little  by  little,  in  several  months  or  several  years,  cause 
in  those  patients  visceral  degeneration  and  death.  For  this 
reason,  I  wish  to  repeat  it  over  and  over  again,  you  must  do 
all  that  can  be  done  to  avoid  fistulaj  —  namely ;  never  open  an 
abscess,  and,  by  every  means,  prevent  it  opening  sponta- 
neously. 

Nevertheless,  all  the  fisluke  in  Pott's  disease  have  not  the 
same  sombre  prognosis ;  it  is  much  less  rare  for  example,  to 
see  those  of  the  neck  cured  than  those  of  the  lumbar  region, 
owing  to  the  relatively  superficial  jDOsition  of  the  vertebral  bodies 
of  the  neck,  whence  the  greater  facility  of  complete  drainage  in 
that  region  (v.  p.  3  2  5). 

Orthopoedic  treatment  of  fistulte  in  Pott's  disease. 

Plaster  the  patient  in  order  to  immobilize  the  affected  focus 
and  to  lessen  pain,  Avhich  is  often  severe.  The  apparatus 
should  have  an  opening  in  it  to  allow  of  dressing —  or  it  may 
be  bivalve  and  removable  (v.  p.  35o). 

Medical  treatment  of  symptoms  :  if  there  is  albuminuria, 
milk  regime.      If  there  is  fever,  cryogenine,  etc. 

D.  —  TREATMENT  OF  PARALYSIS  IN   POTTS'  DISEASE 

The  indication,  as  I  have  already  pointed  out  (p.  270),  is 
to  remove  pressure  from  the  cord. 


I  HE    TKEATMENT    OK    PA  UAI.\  SIS.  'ill'] 

By  so  dniii-.  llit^  causes  df  lln'  paral\  sis  cxtriiial  Id  llic 
cord  are  acted  on.  as  well  as  llic  iniliirHin  of  llic  cord  ilsdl. 

Thai  is  olTecled  siiiipix  l).\  llic  application  of  a  large  plasUr. 
There  is  already  relief  IVoni  the  pressure  on  the  cord  by  the 
slight  extension  made  daring  the  application  of  the  plaster,  and 
Ihis  relief  isfurlher  augmented  b)  the  pressure  made  afterwards 
upon  the  gibbosity. 

The  apparatus  should  be  constructed  a\  ilh  the  Irunk  in  a 
vertical  position,  but  supported  (v.  fig.  246,  p.  278),  as  shewn 
by  my  assistant,  D"^  Privat,  in  such  a  way  thai  there  is  not  too 
great  traction  on  the  head.  Complete  suspension  would  be 
painful,  badly  borne,  and  might  give  rise  to  sloughing. 

If,  on  the  other  hand,  the  patient  remain  seated,  he  will 
not  be  fatigued,  aud  you  can  leave  the  apparatus  to  dry  with  the 
trunk  in  the  vertical  position.  That  is  a  good  condition  for  its 
being  correctly  applied  and  producing  its  full  effect,  besides 
causing  no  injury  to  the  tissues,  generally  in  a  poor  condition. 

When  the  paralysis  has  reached  up  to  the  loins,  sores  may 
appear  on  a  level  with  the  pelvic  girdle  if  the  plaster  is  not 
very  exactly  applied,  and  produces,  by  its  roughness,  abnormal 
pressure  at  certain  points. 

Note  that  in  the  case  of  incontinence  of  the  intestine  and 
bladder,  the  plaster  is  easily  soiled.  It  is  necessary  to  take  a 
thousand  slight  precautions  to  avoid  such  soiling  and,  from 
time  to  time,  to  take  off  the  softened  portions  and  replace 
them  by  new  strips  and  new  plaster  scjuares,  by  Avhich  means 
it  is  possible  even  in  the  case  of  extensive  paralysis,  to  preserve 
the  apparatus  which  is  so  useful  in  relieving  the  spinal  cord. 

Treatment  of  symptoms.  —  If  there  are  contractures  of 
the  limbs,  you  may  combat  them  by  continuous  extension,  <5r 
bv  small  plaster  apparatus.  You  contend  against  constipation 
by  suppositories,  simple  enemata,  etc.,  and  against  bladder 
retention,  by  diuretics,  which  suffice  nearly  always,  without 
catheterism  (V.  p.  7^,  the  treatment  of  sloughs). 


348  SUB-OCCIPITAL  pott's  disease 


SUB-OCCIPITAL  POTT'S  DISEASE 

Authors  devote  a  special  chapter  to  the  treatment  of  this 
particular  condition.  That  seems  to  me  perfectly  useless,  for 
there  is  nothing  about  it  which  is  not  contained  in  the  prece- 
ding pages,  either  as  to  orthopedic  treatment  (see  :  large 
apparatus),  or  as  to  the  treatment  of  abscess  (see  p.  ikl  retro- 
pharyngeal abscess),  or  as  to  the  treatment  of  paralysis. 

POTT'S  DISEASE  IN  AN  ADULT 

In  the  same  way  we  do  not  see  any  necessity  for  adding  a 
chapter  on  Potts'  disease  in  the  adult,  in  spite  of  its  great 
frequency  (even  at  an  advanced  age). 

It  is  sufficient  to  know  that  the  absence  of  gibbosity  is  less 
rare  in  Pott's  disease  in  the  adult  that  in  that  of  the  child, 
—  that  the  disease  is  announced  more  often  by  spinal  pains 
or  girdle  pains  of  terrible  acuteness.  —  that  these  pains 
may  precede  by  several  months,  and  even  by  one  or  two 
years,  the  appearance  of  the  gibbosity,  —  and  that  such 
unexplained  sufferings  should  make  you  think  (even 
without  a  gibbosity)  of  a  possible  Pott's  disease,  for  the 
other  signs  of  which  you  will  search.  |(see  diagnosis  p.  246). 
Think  also  of  Pott's  disease,  in  the  presence  of  every  cold 
paraspinal  abscess,  or  of  paralysis  supervening  without 
appreciable  cause,  in  an  adult  as  well  as  in  a  child. 

The  treatment  is  the  same  as  in  children. 

It  is  necessary  however  for  us  to  accord  special  attention 
to  these  cases  of  Pott's  disease  in  the  adult  which  go  on  for 
eight,  ten  or  fifteen  years,  with  girdle  pains  or  pains  in  the 
members,  remittent  or  continuous  pains  Avhich  produce  the 
effect  of  rheumatic  pains.  (This  form  is  seen  also  in  children, 
but  much  more  rarely  than  in  adults). 

What  is  to  be  done  against  this,  fortunately,  exceptional  form? 


poll's    I)l-r.V>i:    l\     I  HE    ADULT  3^9 

N\  ('  cannol  coiiJl'iuii  tliese  patients  to  Ihe  rcciimljont  po- 
sitiiin  tor  fifteen  years!  Lcl  llum  walk  aboiil,  but  not  without  a 
f;oocl  corset,  and  forbid  all  fatigue. 

You  will  contend  directly  against  the  symptoms  of  pain  hy 
counter-irritation  over  the  spine  or  over  the  limbs,  by  cautery 
or  continuous  extension  of  ihe  lowf  r  limbs,  made  during  the 
night,  etc. 

AA  e  shall  sec  thai  these  forms  of  dry  caries  which  persist 
indefinitely,  can  be  found  in  other  parts  of  the  skeleton.  But, 
in  the  spine,  the  pain  mav  be  due  to  anotber  cause. 

Treatment  of  gibbosities  in  the  adult. 

a\  Gibbosity  which  is  in  progress  (with  all  the  sign*  ol'  a  vertebral  focus 
still  in  activity)  :  one  arrests  and  corrects  it  as  in  a  child. 

6)  Gibbosity  already  ankylosed  (one  which  has  not  increased  more  than  a 
millimetre  lor  at  least  two  years,  but  which  offers  at  the  same  time  the  other 
signs  of  an  extinct  Pott"s  disease)  :  there  is  nothing  or  almost  nothing 
to  hope  for  in  attempting  it's  correction . — But  you  will  never ihcless  put 
on  a  corset  if  tlae  patient  complains  of  erratic  pains,  in  order  to  endeavour  to 
attenuate  them;  for  it  is  possible  even  in  Pott's  disease  which  is  ivelded  and  extin- 
guished, to  have  neuralgias  of  the  trunk  and  of  the  members,  due  to  pressure  on 
the  nerves  at  their  exit  from  the  spine,  —  the  cause  of  the  pressure  persisting 
for  a  longer  or  shorter  time  after  the  cure  of  the  tuberculous  focus. 

The  bivalve  plaster  iv.  p.  158")  renders  some  service  in  adults  intolerant 
or  emphysematous. 

POTT'  DISEASE  CO-EXISTENT  WITH  OTHER 
TUBERCULOUS  AFFECTIONS  (hip  disease,  etc.) 

In  all  tbese  cases  you  Avill  treat  the  Pott's  disease  by  a 
corset  (plaster,  at  first;  celluloid,  later). 

If  it  is  a  coxitis  v.  p.  lyl)  without  pain  or  deformity,  exten- 
sion will  be  sufficient  to  keep  the  leg  in  good  position.  If,  on 
the  contrary,  there  is  pain  and  deformity,  make  a  plaster  Avhicb 
vou  Avill  join  on  to  the  plaster  corset.  In  all  other  cases 
(v.  p.  667)  you  will  carry  out  the  treatment  of  the  two  aflec- 
tions  at  the  same  time. 


35o 


THE  REMOVABLE  PLASTER  CORSET 


APPENDIX  TO   CHAPTER  V 

Three  additional  notes  upon  the  treatment  of  Pott's  disease. 
1°'  The  removable  plaster  corset. 

It  is  very  easy  to  construct.  Make  an  ordinary  plaster  corset,  using  cold 
water  without  salt,  and  ^Yllen  dry,  after  a  few  hours,  or  the  next  dav,  divide 
it  by  symmetrical  lateral  incisions,  into  two  valves,  anterior  and  posterior, 
(fig,  329.) 

To  avoid  the  risk  of  damaging  the  skin  in   cutting  the    plaster,  vou  will 


Fig-.  829.  —  A  medium  bivalve  plaster. 


place  over  the  jersey,  at  the  level  of  the  four  lines  previously  chosen  for  the 
incisions,  woollen  strips,  or  better,  zinc  strips,  the  same  as  those  used  for 
moulding. 

The  jersey,  Avhich  remains  adherent  to  the  inner  surface  of  the  apparatus, 
will  serve  as  a  natural  lining. 

In  order  to  apply  the  removable  plaster  corset,  you  replace  the  t\^  o  pieces, 
so  that  they  are  in  perfect  contact  at  their  edges,  and  you  keep  them  so  either 
A>ith  straps,  or  with  some  turns  of  gummed  muslin,  moist  and  squeezed  out; 
better  still  with  laces  passing  round  dressmaker's  books.  These  are  stitched 
to  strips  of  linen  which  have  been  fastened  to  the  edge  of  the  apparatus  ^A"ith 


A    WolU)    UPON    SLOUGHS 


35f 


(lie  [il.i-lor  cr.'ain,  or  w  illi  silicate,  or  even  nilli  oi-Jiiuir\  glue.  [I'lg.  288.) 
^  nil  slioiilil  ii-f  the  rcinovaI)le  apparatus  only  in  very  limited  cases, 
uamel>.  wliea  lliere  arc  numerous  fistuhe,  or  a  skin  needing  daily  attention, 
or  again,  in  an  emphysematous  or  neurotic  person  who  will  only  be  able  to 
become  accustomed  to  the  plaster  gradually,  keeping  it  on  at  the  ber'inniii"- 
for  a  few  hours  only  every  day. 

2'"'.     Upon  sloughs. 

We  have  described  (p.  72)  what  are  their  causes,  their  situation  and  their 
treatment.      ^\  e  have  only  one  more  word  to  add  here. 

If  the  slough  is  situated  over  a  gibbosity,  do  not  cease  compression  for  a 
single  day;  for,  if  the  compression  is  regular,  it  will  not  hinder  the  cure  of 
the  child,  and  thus  you  will  have  lost  nothing  froua  the  point  of  view  of  cor- 
rection of  the  gibbosity.      If  the  slough  is  situated  at  the  chin,  vou  make    a 


Fig.  33o.  —  Strip  of 
linen  with  hooks  wliich 
you  glue  to  tlie  edges 
of  the  plaster. 


33 1.  —   Removable  plaster, 
completely  finished. 


notch  in   the  plaster    at    this  point   to  allow  of  its  dressing 
anticipate. 


All  this 


3''^.     On  the  use  of  chloroform  in  applying  the  plaster. 

Sometimes  little  children  throAA  themselves  about  violentlv  under  the 
sustension  apparatus;  to  prevent  traumatism  of  the  morbid  focus,  anaesthetise 
tliem.      lou  may  [>ut  them  to  sleep  in  the  upright  position,  held  by  the  strap,. 


d02  NARCOSIS   IN   THE   APPLICATION    OF   THE   PLASTER 

immobilising  firmly  tlie  head  and  trunk,  during  the  first  whiffs  of  chloroform. 
Contrary  to  what  is  generally  thought,  chloroform  is  wonderfully  well 
tolerated  in  an  upright  position,  when  the  chin  is  kept  raised  as  it  is  by  the 
i?trap.  The  last  bandage  being  rolled,  you  lay  the  child  on  the  table  to  dry 
the  plaster,  for  if  it  should  dry  in  the  upright  position,  under  the  ana?sthetic, 
the  trunk  AAOuld  be  too  much  extended.  ^Mience,  a  little  risk  of  ulterior 
slough  beneath  the  chin,  (if  you  are  preparing  a  large  corset),  and  the  appa- 
ratus would  perhaps  be  too  tight. 

li  ou  may  also,  in  order  to  lessen  the  traction  produced  by  the  weight  of  the 
Ijody,  put  children  to  sleep,  and  apply  the  plaster  in  the  sitting  position 
rather  than  in  the   upright. 

That  will  be  better  so.  Restless  children  will  (like  cases  of  Pott's  disease 
with  paraly  sis)  be  kept  seated  on  a  bicycle  saddle  as  represented  in  fig.  2/15, 
p.  278. 


CHAPTER  VI 

HIP-DISEASE 


A   word  on  the  symptoms,  the  prognosis  and  diagnosis 
of  hip -disease 

Hip  disease  is  tuberculosis  of  the  hip-joint. 

The  minute  tubercle  may  rest  silently  for  several  months,  then, 
one  fine  day,  it  makes  itself  known  by  certain  pains  in  the  hip 
or  the  knee,  or  bv  a  slight  limp  (due  to  cramp  in  the  peri-articular 
muscles). 

Clinical  characters. 

A.  Deformities.  —  The  pains  and  the  limp,  intermittent  at 
the  beginning  will  soon  be  almost  continual:  and  a  deformity 
appears,  scarcely  appreciable  at  first,  then  very  distinct.  There  is  a 
saddle-like  curve  in  the  lumbar  region,  produced  by  a  flexion  of  the 
thigh;  there  is  a  slight  lengthening  of  the  leg.  produced  by  abduc- 
tion of  the  thigh. 

Thus,  at  the  beginning  of  hip-disease,  the  affected  leg  appears 
to  be  the  longer,  because  it  is  in  abduction.  Later,  the  affected  leg 
■will  appear  the  shorter,  because  it  -will  be  adducted. 

At  the  last  period  of  the  disease  it  will  often  be  really  shorter 
bv  reason  of  atrophv  of  the  bone  and  partial  destruction,  or  even 
complete  destruction,  of  the  articular  extremities. 

B.  Abscess.  —  The  tuberculosis  may  break  down  the  barriers 
of  the  articulation  and  be  carried  towards  neighbouring  parts,  in  all 
directions,  leading  to  abscesses  Avhlch,  if  they  are  not  prevented,  will 
cause  ulceration  of  the  skin  and  open  outwardly,  producing  fistulas. 

C.  Fistulse.  —  These  easily  become  infected,  whence  there  is 
danger  to  life,  not  so  great,  however,  as  in  the  case  of  fistulse  in 
Pott's  disease. 

D.  Luxations.  —  Bv  reason  of  the  wearing  away  of  bone  and 
the  articular  dislocation  which  is  brought  about  by  the  tuberculous 

Calot.  —  Indispensable  orthopedics.  25 


354 


ITS    PROGIN'OSIS 


process,  it  may  produce,  not  only  deformities,  but  veritable  luxa- 
tion of  the  femur  upwards  and  backw  ards. 

The  disease  will  thus  terminate   -with  deformity  and  very  ugly 


Fig.   332.  —  Normal  hip-joint.  —  The  relations  of  the   crural    arch  and  the  artery 

^Yith  the  skeleton. 

shortening  unless  the  patient  is  carried  oflf  by  the  visceral  degenera- 
tions caused  by  the  infected  fistulae. 

What  one  knows  very  well,  however,  is  that  hip-disease  does 
not  follow  this  course  unless  it  has  not  been  (at  least  not  carefully) 
looked  after,  and  that,  even  in  the  case  where  it  has  not  been 
treated,  it  may  be  arrested  spontaneously  at  some  one  of  the  stages 
indicated  above. 

Prognosis. 


But  the  prognosis  of  hip-disease  changes  altogether  when  it  is 
well  attended  to. 

i^'.  We  can  prevent  or  correct  the  deformity  and  thus  prevent 
luxation. 

2"'^.  We  can  prevent  the  opening  of  abscesses,  which  means  the 
formation  of  fistulse ;  and  in  doing  away  with  fistulae  we  do  away 
also  with  the  great  danger  to  life  which  threatens  the  patient. 


PROGNOSIS   ACCOKDING    AS    IV    IS    TUEA  lEI)   Oil    NOT 


355 


3"'.  ^^  c  can  prevent  llie  tieslruclion  of  the  aiiieular  exlivini- 
tics  in  liip-discase  taken  in  hand  at  the  bei^'inning. 

But  that  whieh  wo  are  unable  to  prevent  absolutely  in  every 
case,  is  tlie  slillcning  ol"  the  hip  joint,  or  again,  the  formation  of  an 


A'-' 


Fig.  333.  —  The  normal  liip  joint.  —  Relations  of  the  head  of  the  femur  to  the 
vessels.  —  The  stippled  part  above  the  accessible  zone  of  the  head  represents  the 
cotyloid  ligament.  —  The  t^vo  thick  dark  tracks  are  the  artery  on  the  outer  side, 
the  vein  on  the  inner.  —  The  artery  crosses  the  head  at  the  junction  of  its  inner 
third  and  outer  two  thirds. 


abscess  and  the  production  of  a  certain  amount  of  atrophy  of  the 
bones  of  the  lower  limb,  the  consequence  of  ^vhich  is  slight 
shortening. 

Nevertheless,  shortening  and  ankvlosis  ^vill  not  supervene, 
except  in  neglected  patients,  and  in  some  cases  of  hip  disease  of  a 
serious  character:  in  the  other  cases  we  can.  if  we  have  attended  to 
the  patient  very  early,  secure  him  a  normal  or  reasonably  normal 
limb:  moreover  a  coxalgic,  cured  with  a  shortening  of  one  or  two 
centimetres  and  a  stiff  hip  joint,  is  able  to  walk  well  (for  a  length 
of  time  and  correctly j. 


356 


HIP   DISEASE. 


ITS    DURATIO>" 


The  duration  of  the  disease. 


It  lasts  approximately  one  year  in  the  benign  forms ;  from  two 
to  three  years  in  the  ordinary  forms  ^ ,  -with  or  AA'ithout  abscess  —  and 
4,  5,  6,  7,  years  and  more  in  certain   forms  of  dry  caries  without 


Pectine. 

V.    fern. 

Bourrelet. 

A,   fem. 

Capsule. 

Psoas. 

Couturier. 

Dr.  ant. 
Tens.  f. 


Fig.   334   —  Normal  hip  joint.  —  Horizontal  section  of  an  upright  subject  through 
the  line  A.  B.  in  the  preceding  figure. 

abscesses,  which  progress  Avitli  an  extreme  slowness  and  seem  to  go 
on  for  ever. 

Diagnosis. 

It  is  only  difficult  sometimes,  at  the  onset  of  the  disease. 

Aphorism.  —  When  you  are  consulted  Avith  regard  to  a  child 
or  an  adolescent  Avho,  without  appreciable  cause,  has  been  taken 
with  limping  or  pain  in  the  hip  or  in  the  knee,  think  of  the  possible 
existence  of  hip  disease  and  satisfy  yourself  of  the  correctness  of 
your  diagnosis,  by  examining  the  subject  completely  naked. 

I.  We  shall  see  that  with  early  injections  the  duration  of  hip  disease  is 
reduced  by  more  than  two  thirds. 


DIAGNOSIS    OF   COMMENCING    COXITIS 


357 


Make  him  lie  Hal  on  a  table  and  Unci  out  if  jie  has  pain  on 
pressure  of  ihe  hip,  or  a  limitation  of  movement,  particularly  of 
the  movement  of  abikiclioii. 


Fig.   335.  —    a.  Femoral  artery.  —   z.    Zone,    outside  the  artery,  \Yhere   one  must 
press  in  seeliing  for  pain  on  pressure  of  the  head  of  the  femur. 


Fig.   336.  —  One  presses  with  the  index  finger  in  searching  for  the  pain. 


358      HIP    DISEASE.    DIAGNOSIS.     I*\     PAO    ON    PRESSURE    OVER   THE 

V\  Look  for  pain  on  pressing  the  head  of  the  femur  (v.  fig.  335 
to  337).  Run  your  index  finger  in  front  of  the  suspected  hip 
joint,  along  the  fold  of  the  groin,   at  one  centimetre   outside   the 


\ 


Fig.  337.  —  Examining  the  sensibility  of  the  head  of  the  femur  hy  pressure  over  its 
outer  side.  The  index  finger  is  pushed  inwards  at  a  centimetre  above  the  upper 
border  of  the  trochanter. 

femoral  artery  which  you  will  feel  beating.     You  are  right  over  the 
head  of  the  femur. 


Fig.  338.  —  Tiie  second  sign  of  any  kind  of  arthritis  of  the  hip.  Here  onesees  limi- 
tation of  abduction  on  the  right  side  (affected  side)  compared  with^  extreme 
abduction  on  the  left  (sound)  side. 


Press  upon  it  gently  :  if  the  patient  gives  a  cry  it  is  useless    to 
persist ;  otherwise,  press  more  firmly,   until  the   patient  complains. 


iiL.vu  ui'  THE  fi:mi'k   :    •.?"".   limitation  of  abduction      359 


Antl  find  if,  on  making  an  idontic;il  pressure  over  the  liead  of  the 
fonmr  of  lln-  other  side,  al  a  svniinelrical  point,  you  provoke  an 
cxacllv  similar  sensation  there . 

Do  this  again,  if  need  be,  live  limes,  ten  limes,  pressing  first  on 


Pijr    33f,.  —  Limitation  of  movement  of  flexion  represented   bv  the  dotted  line.  — 
The  Iprinted  lines  show  the  extreme  normal  flexion. 

the  one  side,  then  on  the  other  until  \ou  are  certain  whether  there 
is  or  is  not  a  difference  between  the  two  sides. 

2"''.     Search  for  limitation  of  movements  (fig.   338,  339,  34o).  — 


Fia.  3^0.   Limitation   of  movement  in    extension  and   the  manner  of   making   the 

examination. 

You  fix  the  pelvis  with  one  hand  and  with  the  other  you  take  hold 
of  the  knee,  the  leg  being  flexed  on  the  thigh,  and  you  move  the 
limb  in  difl'erent  directions  up  to  the  extreme  limit  of  movements 
possible  :  flexion  and  extension,  etc.  For  abduction,  you  commence 
the  movement  by  a  direct  flexion  of  the  thigh  up  to  an  angle  of  90^ ; 
then,  from  that  "you  move  the  thigh  in  abduction,  as  far  as  possible. 


36o  HIP-DISEASE   AT    THE    ONSET.    DIAGNOSIS 

Compare  the  extent  of  the  movements  on  the  two  sides  :  then  again 


Fig.  341.  —  Lengttening  of  the  affected  leg    right  .  Notice  there  is  no  longer  only 
arthritis  of  the  hip  of  some  kind,  but  true  coxitis. 

repeat  the  proceeding,  ten  times  if  necessary.      If  there  is  pain  on 


Fig.  3^3-  —  Atrophy  of  the  thigh,  another 
important  sign  though  not  pathognomo- 
nic), of  true  coxitis.  The  thickening  of 
the  skin  is  the  indication  of  this  atrophy 
of  the  thigh.  The  cutaneous  fold  is 
thicker  on  the  affected  side. 


Fig.  3^2.  —  Lowering  of  the  fold 
of  the  buttock  on  the  side  affec- 
ted indicating  also  lengthening. 
On  the  other  hand,  the  projec- 
tion of  the  trochanter  is  more 
marked  on  the  sound  side. 


Fiff 


34i.  —  Cutaneous  fold  thinner  on  the 
thigh  of  the  sound  side. 


PATUOOOMOMC    SIGN 


•ENGTHEMNG    OF    THE     I.IMH 


30  I 


pressure,  aiitl  a  limitation    of    the    movement  of  abduction,  }Ou 

ina\  lie  sure  llial  the  hip  is  diseased. 

Hul  liow  do  Noii  know  il  is   real   coxitis? 


Fi".   S.'io.  The  most   Ircquenl  conclilion      —   Lumbar  hollowing  and  flexion  oi   the 

knee,  verv  apparent  on  the  first  examination. 

By  the  existence  of  lengthening  (apparent)  oT  ihc  ailccled  limb. 
3'"''.     Look  for  lengthening  of  the  limb.  (Pathognomonic  sign.) 

(Fig.  34i  and  342.) 


Fig.  3/|i3.  —  The  same.     The  hollowing  is  more  pronounced  when  the  knee  is  pressed 
upon    the  dotted  line  indicates  the  original  hollowing  . 

Without  paying  particular  attention  to  the  position  of  the  two 
iliac  spines,  bring  the   two  heels   together  and  see   if  the  internal 


Fiff.    3/17.  _  The  same.      The   hollow   disappears  on   Hexing   the  knee    further     ^the 
dotted  line  indicates  the  original  hollow "l. 


malleoli  and  the  heels  are  on  the  same  level.     If  there  is  a  difference 
of  a  few  millimetres,  that  suffices  to   confirm  the  existence  of  hip- 


36: 


HIP-DISEASE.     DIFFERElVriAL     DIAGNOSIS 


disease,   at   the    outset ;    for   later,    we   repeat   it,    there  is,  on    the 
contrary,  shortening  of  the  alTected  side. 

Failing  the   characteristic  lengthening,   you  will  make  the  dia- 
gnosis hy  the   existence  of  some   small   glands  in  the  groin  of  the 

suspected  side,  by  slight  atrophy  of 
the  muscles,  or  thickening  of  a 
fold  of  skin  on  this  side  (fig.  343 
and  344)>  by  the  absence  of  any 
history  of  injury,  or  of  scarlatina, 
or  of  rheumatism,  by  the  insidious 
onset  and  the  characteristic  inter- 
mittence  of  the  symptoms,  by  the 
general  condition  and  the  bad 
antecedents  of  the  patient,  etc. 
In  doubtful  cases,  reserve  your 
diagnosis  and  ask  to  see  the  child 
again.  If  then  \ou  find,  after  a 
fcAV  weeks,  pain  on  pressure  and 
limitation  oi'  movement,  you  "will 
conckidc  it  is  hip-disease. 

Differential  Diagnosis. 

a.   Diseases  not   affecting    the 

hip  :  White  swelling  of  the  knee, 
or  sacro-coxitis,  or  Pott's  disease. 

You  must  always  think  of  these, 

that  is  to  say  that  after  examining  a 

hip-joint,   \ou   ought   to  examine 

the     pelvis,    the   lumbar   column 

and    the  knee.      If   the   disease  is 

situated  in  those  regions,  it  is  there 

and  not  in   the  hip    that  you  Avill 

find  the  most  apparent  characteristic   signs  ;   pain   on  pressure  over 

the  bones,  limitation  of  movement,  etc. 

b.  Other  diseases  of  the  hip-joint. 

Osteo-myelitis  of  the  hip  begins  with  great  constitutional  disturbance 
and  a  temperature  of  from  39°  to  4o°,  etc. 

Infantile  Paralysis.  There  is  no  rigidity  (on  the  contrary 
abnormal  laxity),  no  pain  on  pressure.  —  Atrophy  and  enfeeble- 
ment  of  muscles  greater  than  in  hip-disease.     The  history. 

Congenital  Luxation.     The  affected  leg  is  not  longer  but  shorter  ; 


Fig.  3i8.  —  The  same.  —  Riglit  coxi- 
tis. —  Abduction  and  lengtliening 
very  apparent  on  standing  upright; 
the  patient  bends  naturally  the 
linee  on  the  alTected  side. 


lIll'-DISEASn. 


DiriEUKN'l  lAI.    1)1  AONOSIS 


S6S 


llio  child    N\as  laic  in  walkirii;,  lias  always  had   a   sliirht  limp,  a 

sort  of  dip;  no  pain.  Von  no  longer  (col  the  head  of  iho  fomur 
in  froiil  a^ainsl  ihc  arlcrv  ;  at  its  usual  place  there  is  a  void,  but 
one  can  feel  the  head  more  or  less  displaced,  outwards  and  upwards, 
against  the  anterior  superior  iliac  spine  (v.  fig.  789). 


Fi^.  S.'ig.  —   Verv    marked    deformity,   in    abduction,    lumbar   1io11o\y   and   flexion   of 

the  knee. 

Hysterical  Coxitis...  But  this  is  so  rare!...  Do  not  deceive 
yourself!  it  nearly  always  masks  a  true  coxitis. 

Rheumatism.  In  the  hip  as  in  the  spine,  mistrust  those  mono- 
articular rheumatisms    Avhich   seem    to   last    for    ever.      The    same 


Fig.    35o.   —    The    same. 


The    hollow   is    elTaced    when   flexion  of   the   knee   is 
increased. 


remark  applies  to  the  so-called  '•  growing  pains  " .  How  many  true 
hip  diseases  have  been,  at  the  beginning,  mistaken  for  rheumatism, 
growing  pains,  sprains  ! 

However,  do  not  exaggerate  the  difficulties  of  diagnosing  coxitis. 
In  realitv,  there  is  generally  none  in  practice.  A\hen  you  are 
dealing  with  a  true  coxitis  you  will  nearly  always  notice  at  your 
first    examination   (beside    the   signs    Ave    have   indicated   above)    : 


364  HIP-DISEASE.     THE    ANATOMICAL    LESIONS 

i^',  a  ver\  apparent  lameness;  —  2""*.  a  vicious  attitude  characte- 
rised by  flexion  of  the  thigh  and  a  lumbar  hollo^v,  together  with 
abduction  of  the  limb  (fig.  345,  346,  347,  348,  349,  35o):  —  3"^.  a 
fungous  puffiness  of  the  region  of  the  joint;  —  4"'-  fi  limitation 
(more  than  a  half)  of  the  physiological  movements;  —  5"'.  very 
evident  pain  on  pressure  and  on  movement,  etc. ;  that  means  that 
you  will  find  nianv  more  signs  than  are  necessarv  to  confirm  the 
existence  of  hip-joint  disease. 


A  WORD  ON  THE  ANATOMICAL  LESIONS 

BASED    LPO-\    RADIOGRAMS    IN    MY    COLLECTION    ASD    ON    THE    THESIS 
OF    MY    ASSISTANT    AND    FRIEND    D'    FOLCHOU 

Siir   la  Radiographie  dans   la   Coxalgie,   Paris,    1906. 

All  you  liaNC  to  keep  in  mind  are  the  following  ideas  :  — 

Placing  yourself  at  the  practical  point  of  vicAv,  you  may 
consider  in  hip-joint  disease  two  anatomical  forms  :  one 
Avhere  the  contour  of  the  joint  and  the  bony  formation  are 
entirely  preserved;  the  other  where  there  is  a  softening 
of  the  head  and  roof  of  the  cotyloid  cavity  Icachng  to  a  gradual 
breaking  down  of  the  osseous  extremities,  in  the  course  of 
2,  3,  4,  5  years. 

The  first  form  terminates  without  shortening,  but  the  second 
leaves  an  inevitable  shortening  Avhich  extends  generally  to  3  or 
4  centimetres. 

Let  us  go  into  details. 

The  first  variety  comprises  the  benign  and  recent  cases 
(see  further  on  upon  hip-joint  disease  ot  V'  form.)  which  have 
been  well  cared  for  from  the  beginning;  here,  the  lesions  are 
always  synovial  and  the  bones  are  scarcely  «  touched  «, 
if  I  may  say  so,  by  the  tuberculous  process  (fig.  35 1  and  352). 

The  second  variety  is  more  frequently  the  actual  condi- 
tion of  things  ;  it  comprises  hip-joint  disease  of  the  second, 
third,  fourth,  fifth  and  sixth  form.  The  tuberculosis  here  is 
more  serious,  either  because  from  the  onset  it  was  essentially 
more  malignant,  or,  chiefly,  because  it  has   not  been  looked 


IIll'.rOlNT    DISEASE.    TlIK    AN.VTOMICAL    LESIO.NS 


365 


after  from  the  first  hour  of  its  existence,  or  else,  it   has  been 
badly  looked  after. 


Fig.  35 1 .  —  Radiogram  of  a  case  of  left  hip-joint  disease  of  the  first  form,  without 
anv  appreciable  osseous  lesion,  in  spite  of  the  fact  that,  clinically,  the  diagnosis, 
was  not  in  the  least  doubtful.      It  was  very  probably  a  coxitis  exclusively  sj-novial . 


Fig.  352.  Another  case  of  left   hip  joint-disease  of  the   first  form.     There   is  no 

alteration  in  the  contour  of  the  bone,  but  only  a  diffuse  decalcification  on  this  side 
shewn  bv  a  lighter  shade.  —  The  femur  is  in  abduction. 


366  HIP-JOINT    DISEASE.    DESTRLCTIO.X    OF    THE    BONY 

Tuberculosis    sometimes   excavates    one    or    several    small 


Fig.  353.  —  Schema  of  the  osseous  destruction  in  the  and,  3rd,  'ith  and  5th  forms  of 
Hip  joint  disease.  From  the  primitive  core,  the  destruction  spreads  by  successive 
concentric  zones  as  far  as  the  iliac  bone  and  the  upper  extremity  of  the  femur. 
Ihe  total  wearing  away  of  the  two  extremities  generally  measures  three  or 
four  centimetres  and  it  may  attain  five  or  six  centimetres  or  even  more  in 
some  cases  where  the  head  and  neck  of  the  bone  disappear  almost  entirely, 
^^'^"■y  y^ar  brings  about  a  mean  destruction  of  from  3  to  5  millimetres  in  each 
direction  but  the  softening  has  a  progress  more  or  less  rapid.  The  figures  indi- 
cated here,  have,  of  course,  not  an  absolute  value. 

-caverns  on  the  surface  of  a   bone,  but  this  is  rare ;  more  often 
it  produces  tuberculous  infiltration  which  rarefies  and  softens 


i:\iiii.Mi  rir.s   is    iiii;    nuscii'VL  cause  ok   siioit  iKMNf;       30'- 

(like  damped  sujiar)  iho  licad  ol  (he  iViiiiir  and  llie  looC  of  the 
acelahulmii.  nr  pciliaps  it  is  a  qucslioti  of  a  rarol'\  iiij,'-  oslcilis  of 
the  neighbouring  parts,  \vhi(h  is  not  Inbciculous.  hut  has  been 
produced  round  a  minute  bacilhu\  Incus. 

From  the  lad  of  this  softening,  the  bones  do  not  suddenly 
break  doAvn  but  are  worn  away  gradually  to  a  depth  more  or 
or  less  great.  The  wearing  aAvay  is  produced  especially  if  the 
child  walks  about,  but  it  is  also  produced,  althoufiih  in  a  less 
degree,  even  in  children  who  are  kept  at  rest. 

There  belong  to  this  second  form,  as  we  have  said  : 

i*\  Cases  of  Hip-joint  disease  of  the  first  variety,  that  is  to 
say,  cases  of  hip-joint  disease  which  come  on  with  spontaneous 
and  very  severe  pains,  or  with  a  displacement  of  more  than  20". 

2°'*.  All  cases  of  hip-joint  disease  of  the  following  forms 
(which  are  in  reality  only  coxitis  of  the  second  form  in  a  more 
advanced  state),  namely,  cases  which  have  suppurated  or  are 
fistulous,  and  those  of  the  dry  carious  form.  The  progress  of 
the  lesions  and  the  progressive  Avearing  away  of  tissue  in  the 
second  form  may  by  represented  schematically  by  the  figure 
opposite  (v.  fig.  353). 

AAithout  reckoning  the  examples  of  extreme  destruction 
which  fortunately  are  exceptional,  one  may  say  —  and  this  is 
what  I  wish  you  to  remember  —  that  at  this  present  time  and 
in  more  than  three  quarters  of  the  cases  of  hip-joint  disease  cured , 
we  observe  a  general  wearing  away  of  from  3  to  U  centimetres. 
There  is  in  this  evolution  of  osseous  tuberculosis  something 
special  to  the  hip-joint,  and  which  we  have  not  found  in  white 
swelling  of  the  knee,  nor  of  the  in-step,  where  the  bones  do 
not  decay  and  always  preserve  their  outline.  \A  e  ought  to  add 
that  this  wearing  away  of  bone  is  seen  especially  in  the  hip 
disease  of  children.  In  the  adolescent  Avho  has  completed  his 
groAvlh,  the  bone  Avill  resist  much  better,  and  sometimes  com- 
pletely, the  wearing  and  destructive  process. 

You  will  see  later  on  (p.  385  and  folloAving)  that  the  only 
means  truly  efficacious  of  altering  this  cAolution  of  the  tuber- 


368 


RADIOGRA.MS    OF    HIP    DISEASE    AT    DIFFERENT    PERIODS 


\ 

i 

'^-^^■'^    . 

i 

\ 

1 

1 

Fig.  35/1.  —  Right  hip  disease  at  the 
beginning ;  marked  rarefaction  of 
the  osseous  tissue,  which  appears 
lighter  on  the  affected  side.  The 
articular  interline  is  much  less 
distinct. 


Fig.  355.  —  A  more  advanced  type. 
Right  hip  disease  ;  notable  -wasting 
of  the  head  and  neck  of  femur,  and 
of  roof  of  acetabulum.  Moreover, 
outside  the  trochanter,  there  is  a 
dark  patch,  which  was  found  on 
clinical  examination  to  be  a  small 
abscess. 


Fig.  356.  —  Left  hip  disease ;  Rad.  n°  i 
The    superior   edge    of   the    aceta- 
bulum is  eroded  as  if  scratched  with 
the  nail ;   in  the  eroded  space   are 
seen  two  small  sequestra. 

The  epiphysial  body  is  cut  in  two  by 
a  gap  which  runs  from  the  cartilage 
to  the  interline. 


Fig.  357.  —  The  same  patient  at  the 

end  of  a  year,  after  an  abscess  had 

appeared. 
The  acetabulum  is  very  much  broken 

down,    its   superior   border  raised; 

the   whole   of  the  epiphysis  of  the 

head  has  disappeared. 


KADlor.RAM    or   HIP   DISEASE    SINGLE    AM)    DOLBLE 


3G. 


Fig.  358.  —  Olfl  hip  disease  of  left  side  with  abscess.  Considerable  enlargement  of 
acetabulum  bv  complete  wearing  away  of  middle  portion  of  iliac  bone.  From  this 
destruction  a  kind  of  shrinking  and  telescoping  of  all  the  left  half  of  pelvis  has 
resulted. 

The  head  and  two-thirds  of  the  neck  of  the  femur  have  disappeared. 


Fig.   359.  —  Double  Hip  disease  without  appreciable  abscess    dry  caries). 

On  the  right.  —  The  head  of  the  femur  and  the  upper  half  of  the  neck  no  longer 
ejtist.  The  middle  part  of  the  iliac  hone,  verv  much  softened,  has  given  wav. 
causing  considerable  deformity  of  the  pelvis. 

On  the  left.  —  Disappearance  of  the  head  of  the  lemur  and  enlargement  of  the 
cotyloid  cavilv. 


Calot.  —  Indispensable  orthopedics. 


24 


370 


HIP   DISEASE   WITH   AND    WITHOUT   ABSCESS 


Fig.  36o.  —  Another  case  on  the  right 
side.  Erosion  of  upper  part  of  head 
of  femur. 


J.  36i.  — Right  hip  disease  without 
abscess  (dry  caries) .  Complete 
necrosis  of  femur  and  considerable 
enlargement  of  acetabulum. 


Fig.  362.  —  Pseudo-luxation.  Necrosis  nearly  complete  of  the  head  and  neck,  the 
normal  limits  of  Avhich  are  marked  by  dotted  line  in  the  figure.  There  remains 
only  a  small  stump  formed  by  the  infero-exlernal  part  of  the  neck. 


HIP    DISEASE    WITH    ANKYLOSIS    WD    LUXATION  3-1 


b"ig.  3G3.  —  Anotlier  type  more 
advanced;  complete  necrosis  of  the 
head  and  neck.  Of  the  latter  there 
remains  only  a  small  process  in 
the  form  of  a  spine  >Yhich  is  still 
in  the   cavilv.      Fihrous  ankylosis. 


Fig.  364-  —  Right  coxitis.  —  T^  jps 
of  osseous  ankylosis  in  abducted 
position  (osseous  ankylosis  is  rare 
in  hip  disease) . 


Fig.  365.  —  True  luxation.  The  head  of  the  femur,  or  rather  the^small  stump 
>Yhich  remains  of  it,  is  completely  outside  the  cotyloid  cavity  (the  femur  is'generally 
turned  round  in  external  rotation;. 


372  SIX    VARIETIES.     WHAT   IS    TO    BE    DONE    IN    EACH  ? 

culous  process  in  the  hip  and  of  preventing  its  destruction  is 
to  make  articular  injections,  as  soon  as  hip  disease  is  recognised, 
that  is  to  say,  before  the  bones  have  been  seriously  softened. 

The  ttiree  preceding  figures  summarise  for  you  all  the  lesions  of  hip  disease. 
Those  which  follow  are  radiograms  in  some  way  illustrative  of  fig.  353. 

TREATMENT  OF  HIP  JOINT  DISEASE 

The  treatment  varies  with  each  variety  of  coxitis,.  —  All 
the  varieties  may  be  considered  with  reference  to  the  six 
following  points  :  — 

I.  Without  deformity.  2.  Deformity.  3.  Abscess.  l\-  Fistula. 
5.  Dry  coxitis,  which  maybe  protracted.  6.  Coxitis  which  is  cured 
with  a  defect  (shortening,  ankylosis,  luxation'). 

We  will  first  define  and  illustrate  in  Part  I  the  different 
varieties,  and  shew  you  the  treatment  suitable  for  each  of  them. 
In  Part  II  we  will  describe  in  detail  how  the  treatment  must 
be  carried  out,  that  is,  how  to  apply  the  technique.  We  will 
not  describe  the  general  treatment  of  tuberculosis.  That 
you  know  :  life  in  the  open  air,  in  the  country  or  by  the  sea, 
for  two  or  three  years  at  least,  if  possible;  good  feeding;  the 
4ise  of  medicines  recognised  to  be  good  for  tuberculosis,  etc. 

I.  —  P'  PART.   CLINICAL.  —   THE  SLX    VARIETIES 
AND   THE   THERAPEUTIC  INDICATIONS  IN  EACH  OF  THEM. 

1"    VARIETY.  —  HIP  DISEASE  WITHOUT  DEFORMITY 

Hip  disease  at  the  beginning,  without  deformity  and 
without  spontaneous  pain  (fig.  35i  and  Soa.  p.  365).  (Or 
with  very  little  pain  or  deformity,  for  example,  only  from  10° 
to  20°  of  flexion  or  abduction). 

For  all  these  patients,  you  will  prescribe  rest  in  the 
recumbent  position  for  eight  or  ten  months  at  least. 

You  should  never  alloio  a  patient  with  hip  disease  to  lualk. 

Patients  must  not  be  allowed  to  walk  save  alone  those  of 

I.  We  will  describe  later  on  double  hip  disease,  coxitis  with  Pott's 
<lisea5e,  etc. 


IT    IS   NECESSARY    lUOM     llli:    llllST    T(J    I'lUtHIKIT     \\AI.KIN(;        S'J'^ 


tlie  wiu-kiii^  class  who  are  not  able  lo   he  carried  each  (layout 
of  doors,  atul  lor  whom  kecpin;^^  al  resl  would  mean  therefore 
condemnnig  Ihem  to  moulder  away  in    some  hovel.      In  these 
cases  oiilv.   you   wnuM   ni.ikc  ,i    phisler 
apparatus    down     In    ihe    malleoli,    and 
allow  walking,  bul  wilh  ciulclics  and  a 
liigli  soli'  under  the  Sound  lool,  in  order 
ihal  the  loot  of  the  alTecled  side  does  no! 
touch  the  ground. 

For  all  other  children,  resl  in  the 
recumbent  position  is  infinitely  better 
than  walking,  and  you  will  order  resl 
if  you  have  entire  liberty  of  action. 
However,  if  the  parents  insist  on  their 
child  being  allowed  to  walk,  vou  ma\ 
consent,  provided  he  wears  a  plaster  (in 
many  countries,  nearly  all  practitioners 
readily  agree  to  this  and  treat  tlieir  pa- 
tients in  this  way);  but  you  would  not 
consent  to  il  without  havimj  freed  your 
conscience  and  inruimed  the  parents  thai 
in  walking,  w  hatever  apparatus  be  cho- 
sen, with  or  without  some  arrangement 
for  the  so-called  taking  the  weight  off 
the  trunk',  with  or  without  crutches, 
whether  they  put  the  feet  to  the  ground  Fi 
or  not,  there  is  much  less  chance  of  cau- 
sing cases  of  recent  hip  disease  to  abort 
(those  of  the  first  variety)  and  of  obtaining  the  restitutio  ad 
ntegrum  ;    with  walking,  one  will  more  often  see  produced  an 

I.  Lorenz  and  other  surgeons  after  liaving  much  vaunted,  for  twenly 
years,  the  «  appareils  de  decharge  »  approve  of  them  no  longer,  having  four.d 
fewer  advantages  than  inconveniences,  and  actually  prefer  to  them  tlic 
«  appareils  de  pression  »  of  the  two  articular  surfaces,  that  is,  they  mate  a 
simple  plaster  apparatus  down  to  the  knee,  with  which  their  hip  cases  wa'.k 
on  the  sole  of  the  foot,  without  even  a  high  heel  or  crutches ! 


.  3Gt3.  —  i"  case.  —  Left 
hip  disease  at  the  ontscl, 
without  Wcious  aUitucIc. 


^74  I*''^   VARIETY.     HIP    DISEASE    WITHOUT    DEFORMITY 

aggravation  of  the  lesions  and  the  formation  of  an  abscess.  And, 
if  it  should  be  one  of  the  other  varieties  (second,  third,  fourth  or 
fifth)  you  will  tell  the  parents  that  with  walking,  or  rather  in  spite 
of  walking,  one  will  end  nearly  always  by  curing  them,  it  is  true, 
but  by  taking  much  longer  time  and  leaving  the  limbs  much 
more  shortened  because,  with  the  weight  of  the  trunk  upon  the 
softened  extremities  of  the  bones  — a  weight  which  no  apparatus 
could  do  away  with  —  and  with  the  shaking  and  knocks  inevi- 
table in  walking,  the  lesions  will  progress  more  and  will  leave  a 
wearing  awayand  a  loss  of  substance  of  the  head  of  the  femur 
and  of  the  acetabulum^  more  extensive  than  if  the  child  had  not 
walked,  lou  will  leave  the  question  of  walking  in  the  hands  of 
the  parents,  and  Avhatever  is  the  result,  it  Avill  be  that  which  they 
deserve.  AA  henever  you  have  to  deal  with  reasonable  parents, 
the  child  should  be  put  to  rest  in  the  recumbent  position. 

The  prescription  of  rest  is  not  sufficient.  For  hospital 
children  and  those  of  the  working  classes  you  make  a  large 
plaster  reaching  from  the  umbilicus  to  the  toes ;  your  objective 
should  be  to  cure  rapidly  and  permanently  without  troubling 
here  about  movements \ 

For  toivn  children,  Avell  cared  for  by  their  parents,  do  not 
put  on  a  plaster;  keep  them,  in  mild  cases,  at  i^est  on  [he  frame 
ivith  continuous  extension,  which  will  efface  the  ugly  deformity 
which  may  exist  and  will  give  a  greater  chance  of  preserving 
mobility  than  the  plaster^. 

The  functional  result  to  look  for  in  the  first  variety.  —  Thus, 
then,  contrary  to  what  holds  good  in  Pott's  disease,  Avhere  we 
ought  always  to  look  for  ankylosis  of  the  aflfected  bones  (and 
where,  consequently,  plaster  is  always  indicated)  one  ought,  in  the 


1.  Because,  in  these  children    ((  leave  well  alone  ». 

2.  Would  you  do  more  and  better?  Would  you  make  certain  and  hasten 
the  cure,  well!  make  in  all  these  cases  a  series  of  modifying  inter-arlicular 
injections  as  for  a  white  swelling  of  the  knee.  It  is  a  little  more  difficult  in 
the  hip  than  the  knee.  Nevertheless,  willing  practitioners  may  succeed  by 
means  of  the  technique  given  by  us  further  on,  p.  384- 


1*'"   VAUir/iY.   —  HIP  Disr.vsi;  wrnioui    nKiouMir^ 


.S--5 


first  varielv  <>l  liip  disease,  to  look  U>v  llic  prcservalioii  of  the  arti- 
cular moveiiienis,  when  thai  is  leasible   without  compromising 

the  cure that  is  to  sax.  in  rhildnii  who  are  well  hjoked  after. 

After  Core.  —  The  Irealnieiil  once  commenced,  it  will  be 
sufficient   for   >ou    to    see    the    patient   ayain   once   or   twice  a 


Fig.  367,  —  Left  coxiUs,  and.  variety.  —  Extreme  abduction.  Cosalgia  extremely 
painful.  The  child  has  been  anwsHietised ;  the  redressment  is  about  to  be  carried 
out. 

month.  You  continue  the  treatment  until  the  cure,  which 
you  may  consider  accomplished  in  from  six  to  eight  months 
after  the  disappearance  of  all  pain,  spontaneous  or  on  pressure. 
At  this  moment,  you  get  the  child  up,  helping  it,  in  the  first 
exercises  in  walking,  by  means  of  a  removable  apparatus  m 
celluloid  (v.  p.  4/4,  Convalescence). 


376 


2""''   VARIETY.    HIP    DISEASE    WITH    DEFORMITY 


2°^  VARIETY.     HIP  DISEASE  WITH  DEFORMITY. 
Hip  disease  fully  developed,  accompanied  with  a  mar- 
ked deformity  (of  more  than  20"). 

Deformity  occurs  either  in  abduction  (fig.  352)  at  the  com- 
mencement, with  lengthening  of  the  limb  and  some  pain  ;  or, 
later,  in  adduction  (fig.  368),  with  shorte- 
ning of  the  limb  and,  most  often,  without  pain. 
Generally,  adduction  does  not  occur  until 
after  a  period  of  abduction ;  this  change  of 
attitude  may  occur  all  at  once,  in  one  day, 
with  some  suffering;  but,  as  a  rule,  it  is  pro- 
duced little  by  little,  in  several  days,  and  with- 
out suffering.  In  these  cases  of  deformity, 
there  is  one  treatment  only  to  be  adopted,  in 
town  or  in  hospital  ;  the  redressment  of  the 
hip  joint  —  in  several  stages,  if  the  parent 
object  to  anaesthesia  —  but  better,  with  chlo- 
roform, at  one  or  two  sittings,  each  stage 
being  followed  by  the  application  of  a  large 
plaster ' . 

The  Functional  Result  to  be  sought  for  in 

this  second  variety.  —  In  the  diseased  hips  of 

the  second  variety  (and  in  the  three  following 

varieties),  one  abandons  the  idea  of  preserving 

movement.      One  should  have  for  the  objective  the  cure  with 

a  stiff  hip-joint,  but  in  a  good  position. 

After  Care,  when  corrected. 

The  apparatus  is  changed  about  every  four  months.  —  The 

removal  of  the  plaster  and  the  toilet  of  the  child  are  performed  in 

the  way  described  for  Pott's  disease.      Take  the  opportunity  when 

making  the  change  to  examine  the  state  of  the  diseased  hip-joint. 

Duration  of  rest  (with  the  plaster),      It  will  last  until  all 

I.  For  the  second  variety,  as  for  the  first,  I  advise  you  to  make  intra- 
articular modifying  injections  before  or  after  the  redressment,  but  more  often 
before  (v.  p.  384  aVjout  these  injections). 


iinipie 


5.  368.    —    S 
adduction  (right  hip 
disease) 


VARIETY. 


HIP    DISEASE    WITH    ABSCESS 


377 


|>aiii  liasdisa|)pearo(land  even  six  or  ten  months  from  tliat  time. 
The  child  is  then  got  up,  hut  with  an  apparatus  (plasterer 
celluloiil)  whiih  he  will  wear  day  and  night  until  lie  no  longer 
has  any  tendency  to  a  new  deformity.  But,  such  tendency  still 
generally  exists  one  and  a  half 
or  two  years  after  regaining  the 
feet,  that  is.  after  the  cure  of 
the  tuherculous  process. 

\ou  must  knoAV  that,  in  the 
second  variety,  very  commonly 
(horn  the  twelftli  to  the  twen- 
tieth month)  an  articular  or 
peri-articular  abscess  makes  its 
appearance  :  the  abscess  of  hip 
disease. 

3  ^  VARIETY.  -  HIP  DISEASE 
WITH  ABSCESS  1. 

Abscess  is  produced  in 
about  half  of  the  cases  taken 
((  en  bloc  0 .  It  is  more  generally 
found  in  children  who  Avalk 
about  and  whose  general  condi- 
tion is  indifferent.  The  abscess 
does  not  show  itself  for  nearly 
a  year  or  tAvo  after  the  appre- 
ciable clinical  commencement 
of  the  disease.  It  is  announced 
nearly  ahvays  some  Aveeks  or  several  months  before  its  appearance , 
by  pains  and  night  crying,  occasionally  by  a  slight  evening 
rise  of  temperature  of  87.6  to  38°.  Very  often  it  is  not 
announced  by  anything  appreciable,  and  you  should  noAv  and 
then    look   systematically    for  it,  by  careful    palpation   of  the 


^t?^^:,- 


Fig.  369.  —  The  abscess  is  indicated  by 
a  swelling  limited  to  the  outer  reg^ion 
of  the  thigh,  at  a  level  with  the  upper 
third. 


i.'See  figs.  369  and  870,  also  figs.  355  and  358,  pp.  368  and  369. 


378 


lllP    DISEASE    MITH    ABSCESS 


entire  region  of  the  hip-joint.  You  should  make  this  complete 
examination  and  systematic  search  for  the  abscess  every  month 
or  two  months,  for  example,  in  those  not  plastered;  you  will 
make  it  every  three  or  four  months  in  those  who  are,  that  is, 
simply  at  each  change  of  the  apparatus ;  this  suffices  Avell  in 
practice,   for  an   abscess  always   takes,  at  a  minimum,  several 


■r 


X. 


Fig.    870.  —  Method  of  seai'ching  for  an  abscess;   successive  palpation  of  all  the  points 
with  the  two  index  fingers  placed  thus. 

months  to  form,  and,  reckoning  from  that  moment,  still  five 
or  six  months,  at  a  minimum,  before  there  is  a  risk  of  its  opening. 

The  abscess  may  be  produced  in  front  or  behind  (in  the 
buttock),  outside  or  inside  of  the  region,  upwards,  towards  the 
crural  arch,  or  downwards ,  towards  the  middle  of  the  thigh,  but 
especially  at  the  upper  third  of  it,  in  the  anlero-external  region. 

Finally,  let  us  mention  that  the  abscess  is  generally  the 
index  of  a  serious  form  of  hip  disease,  in  the  sense  that  Ave 
must  expect  a  shortening  of  about  3  cm.  consequent  upon  the 
necrosis  of  the  head  of  the  femur  and  of  the  acetabulum,  which 


TIIKHAl'EUTIC    IISOICA  I'lONS   IN    CASE    or    AISSCESS  ■)7i) 

is  produccil  in  nearly  cver\  case  of  suppurated  coxitis  (v.  p.  .'iOiS 
and  069).  The  softening  and  necrosis  of  the  bones  are  less  in 
the  varieties  without  abscess.  Not  always,  however;  there  are 
sonic  dry  forms  of  hip  disease,  to  which  we  will  return 
(V.  p.  383),  which  brinf^-  about  in  the  long  run  a  necrosis  as 
marked  as  the  cases  of  hip  disease  with  abscess  (v.  fig.  859); 
more  than  that,  these  dry  caries  may  continue  six,  eight  or 
ten  years,  Avhile  hip  disease  with  abscess  may  be  cured  very 
quickly,  in  a  few  months  from  the  day  it  reveals  itself, 
provided  that  you  treat  it  Avith  punctures  and  injections.  This 
is  why  it  would  be  preferable  for  the  patient  to  have  an  abscess, 
which  hastens  the  cure.  In  some  of  those  old  dry  caries  w^e 
often  wish  tliat  an  accessible  abscess  would  shew  itself. 

It  is  true  that  formerly  suppuration  in  the  hip  joint  was 
much  more  serious  than  a  dry  coxitis  —  because,  then,  one 
opened  the  abscesses  and,  by  this  open  door,  by  this  fistula,  there 
penetrated  into  the  tuberculous  focus  septic  germs,  carried  in 
from  Avilhout,  which  engendered  fever,  infection,  visceral  dege- 
neration (of  liver,  kidneys,  lungs),  too  frequently  terminating, 
sooner  or  later,  in  death. 

Therefore,  for  abscesses  in  hip  disease  as  well  as  for  that  in 
Pott's  disease,  the  first  word  as  to  treatment  should  be  not  to 
open  an  abscess,  nor  alloAv  it  to  open  itself  —  The  second,  to 
treat  it  by  punctures  and  injections. 

yS  e  can  summarise  in  a  few  words  the  line  to  follow  in 
the  presence  of  an  abscess  : 

You  must  not  interfere  with  it  until  it  is  easily  acces- 
sible. 

It  is  better  to  deal  with  it  than  to  abstain  from  doing  so, 
if  it  is  accessible,  which  is  nearly  always  the  case. 

It  is  a  pressing  duty,  if  the  abscess  is  threatening-  the 
skin. 

By  interfering  with  it  I  mean,  I  repeat  it,  puncture,  wdth 
injection  afterAvards. 


38o 


4^ 


VARIETY 


HIP   DISEASE   WITH    FISTULA. 


4i\  VARIETY.  -  HIP  DISEASE  WITH   FISTULA 

If   every   surgeon,  in    the   presence   of   an   abscess    in    hip 
disease,  did  his  duty  (in  the  way  we  prescribed)  there  would  be 
no    more    fistula    in    hip     disease.      But 
there  always  will  be,   because —  errare 
humaniim  est. 

W'liat  is  to  be  done  in  the  presence  of 
a  fistula?  We  ought  to  repeat  here  Avhat 
we  have  said  of  fistulce  in  general,  and 
of  those  in  Pott's  disease  (Chap.  Ill  and 
Chap.  V).  We  have  seen  the  way  to  dis- 
tinguish a  non-infected  fistula  from  an 
infected  one,  that  is,  Avith  a  secondary 
septic  infection  added  to  the  bacillary 
field,  but  pure  at  the  commencement. 
The  discrimination  of  the  two  varieties  of 
fistula  is  of  much  importance  in  prognosis 
and  treatment. 

a.     Non-Infected  Fistula. 

Here,  nothing  is  lost  as  yet,  but  it  is 
necessary  to  hasten  the  closure  of  the  fis- 
lula,  because,  in  the  long  run,  it  will  end 
by  becoming  infected  (almost  certainly). 

One  will  make  injections  after  the 
manner  described  on  p.  174,  through  an 
opening  made  in  the  plaster. 

In  the  infected  fistulas,  the  treatment 
is  summarised  in  four  words  :  asepsis, 
fresh  air,  overfeeding,  and  patience. 

6.     Infected  Pistulae. 
Keep  to  the  simple  aseptic  dressings 
as  long  as  there  is  no  fever  (the  absence   of  fever  proves  that 
the  pus  is  discharging  well). 

When  fever  supervenes  and  persists  for  several  days  or  several 


Fig.  371.  —  Edouard  R., 
England  (Hospital  Roths- 
child] admitted  in  July, 
iqoo,  with  seven  infected 
fistulae  and  /|0  degrees  of 
continued  evening  fever. 
After  two  and  a  half  years 
of  persevering  treatment, 
closure  of  all  the  fistulaj 
(without  surgical  opera- 
tion), then  redressment  Ac- 
tually, now  January,  igog, 
he  walks  very  satisfactorily. 


VALUE    OF    RESECTION    IX    HIF    DISEASE  ')  '6^1 

weeks,  one  must  interfere,  for  fever  is  the  enemy.  It's  cause 
must  be  retention  of  pus,  and  it  is  necessary  to  find  out  Avliere 
this  retention  is,  and  drain  at  one  or  several  points,  hut  dmin 
only  with  no  other  desire  than  to  Inin^-  ahout  a  fall  of  the 
tempera  lure  {i\'^.  071). 

If  the  fever  is  overcome  in  this  way  by  drainage,  do  not 
concern  yourself  about  any  operation  with  pretentions  to  radical 
cure.  Above  all,  do  not  make  a  resection  which  «  ^^  ould  carry 
off  everything  »...  yes,  even  the  patient  himself;  these  great 
resections  give  a  new  impulse  to  the  infection  already  existing 
and  consequently  do  more  harm  than  good. 

Resect'-ii  in  Hip  Disease. 

So-called  complete  esection  in  hip  disease  is  a  bad  opera- 
tion;  it  cannot  cure  t^  j  tuberculous  fistula;  indeed,  it  very  often 
aggravates  it.  More  than  that,  it  mutilates  the  patient  —  a 
patient  Avho  has  been  resected  preserves  (Avhen  he  is  cured  ?)  a  limb 
much  less  satisfactory  than  if  he  had  been  treated  without  resection . 

It  is  not  necessary  to  perform  resection  (incomplete) 
except  to  perfect  draina§:e  :  that  is  the  only  indication  and  the 
only  use  of  resection  in  hip  disease.  Believe  me,  the  indication 
for  this  operation  will  perhaps  never  present  itself  to  you,  for, 
personally,  I  do  not  find  it  necessary  to  perform  even  one  a 
year  (on  an  average)  out  of  several  hundreds  of  cases  of  hip 
joint  disease  which  I  have  under  treatment. 

Take  particular  notice  of  this  indication.  In  certain  ca^es 
the  fever  persists  in  spite  of  all  the  drainage  provided ;  if  the 
fever  is  not  due  to  a  general  cause,  it  is  due  to  infected  pus 
being  retained  at  the  bottom  of  the  acetabulum  or  in  the  pelvis 
above  the  perforated  acetabulum,  being  kept  there  bv  the 
presence  of  the  head  of  the  femur,  which  it  will  be  necessary 
for  us  to  remove  entirely  or  partially. 

'\ou  will  perform  resection,  not  with  the  great  idea  of 
doing  away  instantly  with  all  the  lesions  —  that  is  impossible  — 
but  with  the  more  modest    intention   of  doing  away  with  the 


382  HIP    DISEA.se.    RESECTIOX    OF    THE    HIP-JOINT 

retention  of  pus  and  removing  the  infected  sequestra  which  may 
be.  of  themselves,  a  cause  of  fever. 

At  what  moment  would  you  perform  resection? 

In  such  a  case,  one  must  know  when  to  interfere  —  not  too 
soon,  hut  not  too  late. 

Not  too  soon,  that  is,  not  hefore  having  tried  all  the  other 
means  to  make  the  temperature  fall :  peri-articular  drainage,  and 
drainage  below  the  crural  arch,  and,  if  that  will  not  suffice, 
opening  of  the  articulation  or  simple  arthrotomy.  For,  resection 
ought  to  remain  an  operation  of  necessity,  it  must  not  be 
resorted  to  unless  one  is  morally  certain  the  temperature  will 
not  fall  Avithout  it. 

It  is  necessary,  however,  not  to  intervene  too  late  :  I  will 
explain  myself. 

Fever  is  a  danger  vital  to  the  patient,  a  danger  soon  fatal  if  it 
goes  to  from  09°  to  ^o'^.  but  less  imminent  if  it  oscillate  about 
38°.  In  these  two  cases,  it  leads  to  a  visceral  degeneration 
(albuminuria,  fatty  liver,  enlargement  of  the  spleen,  etc.).  If 
one  interferes  only  when  these  are  already  produced  with  a 
certain  intensity,  these  secondary  visceral  degenerations  following 
septic  absorption,  one  would  not  be  able  to  «  rescue  »  the 
patient,  and  the  visceral  lesions  Avould  from  that  time  develop 
of  their  own  accord. 

It  is  better  not  to  wait  until  there  is  albumen  in  the  urine 
(the  urine  must  be  analysed  every  two  or  three  days).  Never- 
theless, when  there  is  only  a  trace  of  albumen,  there  is  still 
time  to  interfere,  but  you  must  be  qnick. 

It  remains  always  well  understood  that  the  cause  of  the  fever 
is  to  be  found  in  the  hip  joint  and  not  in  a  visceral  complication, 
in  which  case  an  operation  unavoidably  incomplete  would  merely 
stimulate  the  visceral  affection  and  the  fever  itself.  In  the  course 
of  the  operation  upon  these  infected  patients  you  should  use  anti- 
septics but  sparingly,  on  account  of  the  kidneys,  lou  prescribe 
a  milk  diet  after  the  operation  (and  even  before)  to  the  same  end. 

If  you  are  in  the  presence  of  a   subject  already  profoundly 


.)'"    \A1UEIY.     —    OI.I)    llll'   CASES    LABELLED     ((    UlIEUMATISM    ))       38.'i 

infecknl,  with  a  sli^'-lil  lingc  of  jaundice,  a  notable  quanlils  ol 
albumen  in  llie  urine,  and  a  liver  projecting  beyond  the  costal 
margin,  llial  is,  witli  all  Ihe  signs  of  an  infection  which  has 
alread\  s|)rcad  tliiough  the  entire  organism  ;  in  such  a  case, 
it  is  loo  laic  to  operate;  you  would  not  cure  your  patient,  you 
would  have,  in  operating  on  him,  every  chance  of  sensihh 
hastening  his  death.     Leave  him  to  die  in  peace. 

This  leads  me  to  repeat  to  you  in  the  form  of  conclusion  : 
A  fistula  in  hip  joint  disease  is  infinitely  more  difficult  to  cure 
than  to  prevent. 

To  prevent  it,  do  not  open  abscesses  and  do  not  allow  them 
to  open  spontaneously ;  that  is  all. 

Recall  our  aphorism  :  «  To  open  tuberculous  abscesses  (or 
to  allow^  them  to  open)  is  to  open  a  door  through  which 
death  will  too  often  enter  o. 

5"'.    VARIETY.   —  HIP  JOINT  CASES   WHICH   GO  ON   INDEFINITELY 

I  wish  to  speak  here  of  those  old  hip  cases  decorated  with 
the  name  of  rheumatism,  and  which  never  come  to  an  end  !  — 
Coxitis  without  abscess,  with  pains  occuring  from  time  to 
time  (due  to  a  dry  caries). 

The  patients  can  get  about  a  little,  they  have  almost  returned 
to  their  accustomed  life,  but  without  ceasing  to  suffer  unmistake- 
ably  in  the  hip,  and  they  find,  from  time  to  time,  that  their 
sufferings  become  so  acute  as  to  oblige  them  to  give  up  walking 
and  return  to  complete  rest  for  several  days  or  several  Aveeks. 

AYhat  is  one  to  do  Avith  these  cases  of  dry  coxitis,  Avhich  linger 
on  for  six  years,  eight  years,  ten  years,  twelve  years?  One 
ought  to  long  for  the  formation  of  an  abscess,  as  Ave  ha\'e  men- 
tioned on  p.  3-9. 

One  Avould  puncture  that  abscess  and  one  Avould  be  rid  of  it 
Avith  a  feAvs  months  of  treatment;  Avhilst  Avithout  an  abscess  the 
disease  might  be  protracted  for  years...  But  an  abscess  Avill 
not  come!  (This  it  not  so  absolute,  however  —  it  may  come 
Avhen  we  are  no  longer  expecting  it). 


384  TREATMENT   OF   HIP   JOINT    DISEASE    BY    INJECTIONS 

Here  are  the  three  alternatives  between  which  you  must  choose 

Either  make  injections,  or  wait,  or  resect, 

P'.  Injections?  Yes,  but  it  is  particularly  difficult 
to  reach  all  the  points  of  a  hip  joint  affected  for  so  long  a  time, 
where  the  surfaces  are  adherent,  partly  or  entirely. 

Try  to,  hoAvever.      I  have  cured  some  such  patients. 

If  the  injections  cannot  give  you,  in  this  case,  a  rapid  cure, 
they  will  not  be  Avithout  some  advantage. 

2°'^.  Wait?  les;  if  the  injections  have  not  succeeded, 
wait  —  placing  the  patient  at  rest,  at  least  at  relative  rest,  not 
allowing  any  walking  without  a  plaster  or  celluloid  apparatus, 
making  nocturnal  extension,  etc.,  and  resuming  the  injections 
once  or  twice  a  year, 

3'''^.  Resect?  There  are  no  indications  sufficiently  pressing 
to  lead  to  this  operation,  which  allows,  by  Avhoever  it  may  be 
done,  so  many  chances  of  leaving  a  fistula,  consequently  an 
aggravation  instead  of  an  amelioration  of  the  patient's  condition. 
A  fistula!  Think  noAv,  if  it  became  infected,  it  might  lead  to 
death,  whilst  the  actual  pain  of  the  disease  does  not,  after  all, 
prevent  the  patient  leading  an  almost  normal  existence.  Resec- 
tion can  be  contemplated  only  if  you  are  a  very  capable  surgeon, 
full  of  confidence,  and  if  the  patient,  quite  aware  as  to  what  may 
happen,  nevertheless  begs  you  to  bring  the  matter  to  an  end. 

And  even  then,  make  him  wait,  induce  him  to  reflect  upon 
it  for  six  months  or  a  year  longer,  before  you  carry  it  out.  If 
he  continue  to  insist,  you  may  operate  on  him,  but  I  think 
this  obligation  Avill  not  occur  to  you  once  in  twenty  times.  If 
you  resect,  endeavour  to  obtain,  by  every  means,  union  by  first 
intention. 

THE  METHOD  OP  MAKING  INJECTIONS  IN  HIP  DISEASE 
The  necessity  for  injections. 

Before  going  further,  I  will  explain  myself  thereupon.  When 
you  have  read  in  the  following  chapter  (Treatment  of  White  Swel- 


EARLY    INTR.V-AUTIGULAU    INJECTIONS  385 

lings)  dial  iiijeclions  are  llie  rpgiilar  Ireatmcnl  of  llicse  arllirites 
(where  they  iiivc  I  lie  same  good  results  as  in  cold  abscesses) 
YOU  will  ask  wliN  I  lia\c  nol  immedialcly  recommended  this 
means  as  ihe  invariable  treatment  in  coxitis,  wliirli  is  only,  in 
fact,  a  white  swelling  of  the  co\o  femoral  joinl. 

Simply  because  this  method  is  more  difficult  of  application 
to  the  hip  than  to  (he  other  joints.  The  articulation  does  not 
lend  itself  to  it,  anatomically,  as  the  knee  for  example.  It  is 
more  deeply  placed,  the  cavity  is  less  accessible  to  the  needle. 
I  do  not  speak  only  of  the  space  between  the  articular  surfaces 
which  are  fitted  together  too  closely  for  the  needle  to  be  able  to 
penetrate  easily  the  interline,  but  also  of  the  synovial  culs-de- 
sac,  Avliere  it  is  difficult  to  introduce  the  injection  Avith  cer- 
tainty. 

The  difficulty  is  especially  great  in  rather  old  cases  of  hip 
disease  Avhere  the  cavity  is  obliterated  by  adhesions,  or  at  least 
very  much  obscured  by  bands  of  membrane. 

That  is  why  injections  are  not  yet  admitted  into  the  current 
practice  in  hip  joint  disease.  But  how  we  ought  to  regret  it, 
and  what  great  benefit  they  would  bring  with  them  !  I  do  not 
hesitate  to  say  that  it  is  only  with  the  injections  that  we  are 
able  to  alter  the  prognosis  of  coxitis,  still  so  grave  from  the 
orthopoedic  jDoint  of  view,  when  other  treatments  are   applied. 

And  if  hip  disease  no  longer  kills  —  or,  at  least  very 
rarely —  since  practitioners  no  longer  open  the  abscesses,  it  still 
leaves  far  too  much  shortening  and  lameness,  in  spite  of  the  best 
fitting  apparatus,  in  spite  of  the  correction  of  deformities. 
This  is  due  to  the  fact  that  tuberculosis  rarefies,  softens  the 
articular  surfaces  of  the  hip  joint,  the  head  of  the  femur  and  the 
roof  of  the  acetabulum,  and  consequently  paves  the  way  to  the 
destruction  and  shortening  which  supervene,  sooner  or  later, 
after  one  or  several  years.  See  under  the  figures  on  p.  871  the 
extent  to  which  this  wasting  and  destruction  of  osseous  tissue  goes> 

But  this  is  not  an  isolated  fact  —  it  is  so  in  more  than  3/4 

Calot.  —  Indispensable  orthopedics.  25 


386         HIP    DISEASE.     THE    ^^ECESSITY   OF   EARLY    OJECTIONS. 

of  the  cases  taken  en  bloc  :  P',  in  all  those  accompanied  with 
abscess,  which  represent  already  half  of  the  cases  of  hip  disease, 
and  2"*^,  in  the  case  of  nearly  all  dry  forms  which  continue 
beyond  one  or  two  years.  That  is  what  occurs  nowadays,  in 
spite  of  rest,  immobilisation,  general  treatment,  etc. 

If  practitioners  are  not  willing  to  do  more,  they  must  be 
resigned  to  see  more  than  three-quarters  o[  their  cases  of  hip 
disease  doomed  to  a  permanent  shortening  of  from  3  to  4  — 


cm. 


Fig. 


Madeleine  J. 


Radiooram  on  arrival. 


on  an  average  ;  and  you   know  that   such  a  shortening  cannot 
exist  without  an  appreciable  lameness. 

What  must  be  done  is  to  seek  for  and  find  the  means  of 
preventing  this,  or  better  still  of  preventing  the  softening  and 
wasting  produced  by  the  tuberculous  fungus ;  the  means  of 
destroying  it  before  it  has  «  eaten  aAvay  i)  the  head  of  the  femur 
and  the  roof  of  the  acetabulum.  Does  the  means  of  des- 
troying the  fungus  or  of  altering  it's  development  exist  ?  \es, 
there  is  one,  but  only  one;  it  is  to  carry  a  modifying  liquid 
right  up  to  it.  The  proof  has  been  made  in  the  fungosities 
of  cold  abscesses  and  other  white  swellings,  which  do  not 
differ  obviously  from  the  fungosities  of  hip  disease. 


JIECESSITV    Of   E.VULY    I.N.I EGTIO.NS 


liSi 


Seeing  ihat  In  lln"  disease  at  ils  coiimiciK^'niciit  (autopsies  of 


Fig-   873.  —   The   same  patieat  alter  sii  moatLs.     Radiogram  takea  at  the  time  the 
injections  ^Yere  commenced. 


Ficf.  87^.  —  The  same  patient  a  vear  alter  the  injections.  \o  other  trace  oi'  the 
disease  remains  except  a  loss  of  osseous  substance  on  a  level  with  the  superior  and 
internal  angle  of  the  neck.  —  Complete  cure  \\i[\i  all  the  movements  inlact. 

cases  of  early  hip  disease  prove  it)  the  lesions  are  always  locaUsecl 


388  INJECTING,    BEFORE    THE   FORMATION   OF    AN   ABSCESS 

in  the  synovial  membrane  and  on  the  articular  surface  of  the 
bones,  Ave  shall  be  able  by  early  intra-articular  injection  to 
attack  the  fungosities  before  they  have  destroyed  the  bone. 

Here,  moreover,  is  a  commentary  on  tuberculosis  of  the  hijJ 
joint  which  is  very  instructive  in  this  respect  : 

Madeleine  J.,  seven  years  old  (from  Paris),  sent  by  my  very 
distinguished  colleague,  D''  Cuneo,  arriving  at  Berck  in  Sep- 
tember, igo3.  The  radiogram  (fig.  372)  sIicavs  that  the  tuber- 
culosis has  destroyed  a  good  third  of  the  neck  of  the  femur  and 
that  there  is  a  sequestrum  at  that  point.  This  sequestrum  it 
had  been  proposed  to  resect  by  a  surgeon  avIio  affirmed  the 
impossibility  of  cure  without  operation ;  but  the  parents  refused 
their  consent. 

As  for  me,  I  did  not  believe  in  the  necessity  of  a  resection 
ior  the  cure  of  the  child  ;  but  I  feared  complete  destruction  of 
the  neck  after  a  short  time  by  the  progress  of  the  tuberculosis, 
which  appeared  very  virulent;  it  was  excessively  painfid,  which 
led  me  to  propose  modifying  injections,  to  which  the  family, 
unfortunately,  objected.  Haifa  year  passed;  the  child  was  not 
better.  I  insisted  again  Avith  the  parents,  telling  them  that,  if  they 
refused,  Ave  should  very  probably  see  in  a  fcAv  months,  the  neck 
destroyed  entirely,  the  head  separated  from  the  diaphysis,  and 
that  grave  and  irremediable  infirmity  Avould  result.  M.  Cuneo  on 
his  part  insisted  and  succeeded  this  time  in  convincing  the  parents. 

Our  fears  AA^ere  only  too  deeply  realised.  A  radiogram  taken 
at  the  time  Ave  commenced  the  injections  (fig.  373)  shoAved 
plainly  that  the  tuberculosis  had  destroyed  nearly  a  third  of  the 
neck  since  the  first  examination  and  the  first  radiogram,  —  and 
that,  in  spite  of  rest,  in  spite  of  the  plaster  and  the  air  of  Berck. 

I  made  a  series  of  injections  of  camphorated  naphtol  after 
the  manner  described  on  p.  166.  I  softened  the  fungosities  and 
obtained  an  appreciable  collection  of  pus  at  the  sixth  injection. 
From  that  time  I  made  punctures  and  injections  to  the  extent  of 
ten  punctures  and  ten  injections  according  to  my  usual  technique 
for  the  treatment  of  tuberculous  abscesses  (see  chap.  HI). 


nil'    DISEASE     :    MAKE    INJECTIONS    IN    ALL   CASES  380 

.V  slraiige  lliiiig  wiiicli  shewed  thai  Ave  had  reached  the 
alTecletl  part  of  (lie  hone  was  that  Ihrough  the  puncture 
n('(>dle,  small  osseous  granules,  debris  of  sequestra  easily  recog- 
nisable, repeatedly  passed  out.  After  this  series  of  injections, 
which  lasted  seven  weeks,  compression  was  made  for  three 
months.  \  year  later,  Ave  took  a  ucav  radiogram  (fig.  37/1); 
not  onl>  had  (lie  destruction  of  the  neck  not  progressed,  but  the 
neck,  on  the  contrary  Avas  slightly  repaired  and  the  cavern 
which  had  appeared  Avas  partly  filled  up.  More  than  that,  the 
sequestrum  had  disappeared.  The  patient  Avas  cured.  The 
neck  has  ever  since  then  become  stronger.  We  saAv  the  child 
three  years  later;  she  had  become  perfectly  cured  Avithout  any 
shortening,  Avithout  functional  damage.  Think  of  the  infirmity 
she  AA-ould  have  had  to  live  through  if  Ave  had  not  made  the 
injections,  or  if  Ave  had  Availed  longer! 

This  proves,  and  we  have  plenty  of  other  cases  to  the  point 
Avhich  also  prove  (fig.  3^5,  876),  that  our  injections  are  able 
to  destroy  the  fungosities  and  to  preserve  the  bones  of  the  hip 
joint  from  rarefaction  and  eventually  destruction. 

lou  see  noAv  AA^hy  I  advise  you  to  make  intra-articular 
injections  at  the  outset,  in  all  cases  of  hip  disease,  as  one  constantly 
does  for  Avhite  SAveUing  of  the  knee.^  And  the  treatment  Avill 
be  even  more  necessary  in  the  hip  joint,  Avhere  the  bones,  as 
experience  sheAvs,  resist  infinitely  less  Avell  than  those  of  the 
knee,  the  destructive  action  of  the  tuberculosis. 

II-  —  Indications  for  early  intra-articular  Injections. 

Because  Ave  have  spoken  of  making  them  in  all  cases  of  hip 
disease,  Ave  do  not  Avish  to  say  that  there  are  not  cases  of  hip 
disease  essentially  benign,  Avhere,  the  lesions  having  been  only 
synovial  and  the  bones  hardly  touched  by  the  tuberculosis,  there 
Avill  certainly  ensue  an  important  osseous  destruction  if  injec- 
tion is  not  carried  out. 

No,  there  are  some  fortunate  exceptions  already  pointed 
out;  but  hoAV  are  we  to  knoAv  Avhich  are  the  cases   Avhich  may 


3qo 


TREATMENT    OF   HIP    DISEASE 


be  cured  in  this  wav   without   subsequent  destruction?     There 
is  no  absohite  criterion. 

There  are  probably  cases  of  hip  disease  which  come  without 


1)  'J  -^' 

Fig.   375.  —  Germaine  G.,  five  years  of  age;  left  liip  disease  before  injection.     The 
joint  -nas  threatened  -with  complete  and  early  destruction. 

spontaneous  pains  or  deformities,  and  in  which  there  is  not,  as 
shown   bv  the  X   ravs,    loreaking   doAvn  nor  even  appreciable 


Fig.  3-6.  —  The  same,  eighteen  months  after  injeclion.     One  can  see  that,  thanks  to 
the  injections,  wasting  has  not  progressed.     The  tuberculosis  has  been  averted. 

rarefaction  of  the  bones,  cases  of  hip  disease  which  have  been, 
on  the  other  hand,  taken  care  of  from  the  outset.  \es,  without 
doubl ;  but  remember,  however,  that  there  is  nothing  certain 
from  this  point  of  view,  thai  nothing  can  give  us  precise  assu- 


\\llt:N    OUGHT    THE    INJECTIONS    TO    HE    MADE  3o  I 

rance  Ihal.  while  wo  arc  keeping  l)ack  our  injections,  the  tuber- 
lous  process  is  nol  secret  I  >  and  silently  rarclying  and  softening 
the  extremities  of  the  bones. 

Consequently,  even   in  Ihcso  cases,  and    because  of  the  loo 


F'r-  377.  —  Radiograui  during  lil'e  after  tlie  introduclion  ol  (lie  needle;  ihe  point 
IS  in  the  interspace.  This  proves  that  one  can  penetrate  there,  but  it  is  uncertain 
and  difficult. 

numerous  uncertainties  whicb   we  have  against    us,    Ave  must 
make  injections  :  that  is,  generally  speaking,  in  all  cases. 

III.  —  When  must  the  injections  be  made  ? 

Me  say,  at  the  very  beginning-  :  as  soon  as  the  diagnosis 
is  estabhshed. 

To  wait  until  there  is  an  abscess,  or  to  interfere  only 
when  the  coxitis  has  lasted  one  or  two  years,  is  a  mistake, 
because  then  it  is  too  bite. 

In  fact,  in  all  hip  disease  lasting  for  one  or  two  years  the 
rarefaction  of  the  bones  is  already  too  marked,  nearly  always, 
for  you  to  be  able  to  save  them  from  Avasting.  A'Nlien  the  hip 
disease  appears  before  the  abscess,  with  a  noticeable  defor- 
mity of  more  than  20",  or  Avith  severe  pains,  it  may  mean  Ave  are 
too  late,  not  always,  nor  even  frequently,  but  in  some  cases. 

The  principle  is  to  make  injections  before  the  bones  are  — 
I  do  not  say  destroyed  —  but  simply  softened. 


Sgs 


HIP   DISEASE     :    THE    I>'JECTIO>S. 


Does  this  mean  that  no  injections  must  be  made  in  cases  of 
hip  disease  Avhich  are  abeady  oldP  No,  they  must  be  made 
because,  with  injections,  if  one  is  not  able  completely  to  prevent 
destruction  (the  bone  being  already  too  much  softened  and 
rarefied),  one  may  still  limit  it  somewhat,  since  it  takes  three, 
four,  and  five  years,  and  more,  to  arrive  at  the  full  extent  of  the 
mischief.  (In  four  cases  of  old  hip  disease  of  two  and  three 
years  standing,  I  have  been  able  to  save,  almost  entirely,  the 
osseous  extremities  Avhich,as  shewn  in  the  radiograms,  had,  on 
the  arrival  of  the  patient,  seemed  doomed  to  complete  destruction). 

IV.  —  The  Technique  of  Intra-Articular  Injections  of  the  Hip  Joint 

First,  you  will  carry  out  the  treatment  in  the  same  way  as 
for  white   swellings.      You  will  find  in  the  following  chapter 


Fig.   878.  —  Dissection    of    the    inguinal    region   to   shew    ihe   accessible    ZOne    ot 

the  synovial  cavity ;  this  zone  extends  Over  the  whole  anterior  surface  of 
the  neck.  —  AA',  horizontal  line  passing  through  the  pubic  spine;  —  B,  ante- 
rior surface  of  the  neck;  —  C,  femoral  artery;  —  D,  Psoas;  —  E,  Sartorius;  — 
F,  Rectus  (B,  is  the  point  of  election  for  puncture) 

(p.  097)  all  about  the  instruments  required,  the  liquids,  the 
number  of  injections,  their  intervals,  and  you  ought  to  read  the 
entire  chapter  before  making  injections  into  the  hip  joint. 


POINTS   OF   ACCESS    TO   THE    Hll'-JOJ.NT 


3y3 


V.  —  The  Points  of  Access  to  the  Hip-Joint. 

To  pcnclratc  inlo  the  cavilv.  llic  [Mnn[  of  election  is  found 
in  front. 

Explore  the  sduiid  liip  jdini;  \(iii  will  be  able  to  leel  below 
tlio  crural  arch,  between  the  sartorius  and  the  artery,  the  head 
of  the  femur  rolling  under  your  finger  when  you  impart  move- 
UKMifs  of  rotation  to  the  knee  (see  fig.  077  and  following). 

In  front,  the  cartilaginous  part  of  the  head  is  directly  per- 
ceptible (thai   is,  (he   part  outside  the  acetabulum)  to  a  height 


Fig.  879.  —  Railiogram  during  life  in  one  of  our  cases  of  hip  disease,  after  the  injec- 
tion of  iodoformed  oil  into  the  synovial  cavity ;  one  can  distinguish  the  shadow  of 
the  capsule  distended  with  the  liquid.  This  is  the  proof  that  you  have  penetrated 
into  the  joint  cavity. 

of  I  1/2  cm.  in  a  child  21/2  cm.  in  an  adult,  and  we  must 
allow  for,  in  addition,  the  cul-de-sac  formed  above  this  point 
by  the  synovial  sac.      This  zone  is  as  broad  as  it  is  high,     ^^e 


Sgl\        I>JECTIO>"S     :    YOU    PUNCTURE    2    CM.    OUTSIDE    THE   ARTERY; 

have  there,  consequently,  an  area  quite  sufficient  for  the  injections. 

To  reach  the  cavity  in    this   zone,  we   have   only    to   pass 

through  the  skin  and  the  thin  muscular  lamina  of  the  psoas  and 

iliacus.      It  is  easy  to  avoid  the  vessels  (artery  and  vein)  Avhich 


Fig.  879  bis.  —  Diagram  drawn  from  nature  in  the  course  of  a  dissection,  after  an 
injection  ^Yitll  metiiylene  blue  of  the  two  hip  joints.  —  On  the  right  side  is  seen 
the  capsula  distended  with  liquid,  between  the  vessel  and  the  psoas  and  iliacus. 
On  the  left,  the  capsule  has  been  incised,  the  head  of  the  femur  is  shewn,  coloured 
blue. 


are  well  out  of  the  way  on  the  inner  side,  as  shewn  in  fig.  078, 
As  to  the  anterior  crural  nerve,  it  is  nearer.      Still,  it  can  be 

avoided  quite  as  easily,  because  it  is  in  close  relation  with  the 

artery,  and   besides,  pricking  the    nerve  would   not  have  very 

serious  consequences. 

But  it  is  necessary  to  enter  into  some  details. 


I  '/>    CM.     BELOW     A    LINE    PASSING    TlIUOLfill    THE    PUBIC    SPINE        3()5 

A\e  liavc  made  more  than  one  Imndi-cd  experiments  on  llie 
cadaver  (injections,  followed  by  control  disscclions)  and  nume- 
rous radiograms  during  life,  ol"  our  cases  of  iiip  disease,  after 
injections  with  iodoform  (v.  lig.  079),  to  cstablisii  in  a  precise 
way  the  technique  of  the  injections.  Here  are  the  practical 
conclusions  drawn  from  our  enquiries. 

\ou  ought  not  to  make  injections  into  the  articular  interline 
—  Avliich  is  not  impossible  (v.  fig.  077)  although  it  is 
difficult  to  reach.  iNeilher  must  you  make  them  on  a  level  with 
the  cartilaginous  part  of  the  head,  because  the  capsule  being  at 
this  level  in  close  contact  with  the  bone,  the  liquid  would  only 
penetrate  into  the  interstice  with  great  difficulty.  You  will 
make  the  injections  into  the  inferior  synovial  cul-de-sac  at 
the  level  of  the  anterior  surface  of  the  neck;  this  cul-de-sac 
possesses  a  certain  laxity  which  renders  the  penetration  of  the 
liquid  relatively  easy. 

Here  are  the  points  fixed  upon.  In  a  child  of  ten  years,  you 
puncture  at  a  point  indicated  by  a  small  cross  in  fig.  38 1.  at 
i  cm.  below  (he  horizontal  line  passing  through  the  pubic  spine 
and  at  1  12  cm.  outside  the  femoral  artery  (Avhich  can  be  felt 
pulsating).  In  an  adult  allow  respectively  i  1/2  and  2  cm. 
(fig.  38oand  38 1). 

Puncture  directly  from  front  to  back.  The  needle  should 
be  pushed  in  to  a  depth  of  from  3  to  4  cm.  in  a  child,  and  from 
5  to  6  cm.  in  an  adult  of  medium  stoutness.  In  a  word,  push  it 
in  until  it  is  stopped  by  the  osseous  plane  (the  anterior  surface 
of  the  neck)  the  resistance  of  Avhich  is  characteristic.  You  will 
always  be  stopped  by  the  bone,  if  you  puncture  at  the  right  place. 

One  may  succeed  by  leaving  the  thigh  in  the  extended  posi- 
tion. But  the  penetration  of  the  liquid  is  facilitated  considerably, 
as  M.  Farabeuf  has  pointed  out,  by  placing  the  limb  in  the 
position  of  flexion  at  from  20°  to  3o-.  with  abduction  and  external 
rotation  of  from  i5°  to  20"  (fig.  383). 

\o\x  understand  then,  that  by  this  slight  flexion  of  the 
thigh,  always  possible  at  the   outset  of  hip  disease,  the  anterior 


396 


TREATMENT    OF    HIP-JOINT   DISEASE 


part  of  the  capsule  relaxes  (as  the  fingers  of  a  glove  are  relaxed  by 
flexion  of  the  hand),  detaches  itself  from  the  bone  and  comes  of 
its  own  accord  under  the  point  of  the  needle,  which  penetrates 
it  easily  (v.  fig.  38/i  and  385). 


Fig.  38o.  —  In  an  adult,  puncture 
I  1/2  cm.  beIo\Y  the  horizontal  line 
passing  through  the  pubic  spine, 
and  at  2  cm.  outside  the  artery. 


Fig.  38 1.  —  In  a  child  of  from  9  to 
10  years  of  age,  at  i  cm.  below  the 
horizontal  line  and  at  i  1/2  cm.  out- 
side the  artery. 


The  injection  being  pushed  home,  place  a  tampon  over  the 
puncture  and  lay  the  thigh  gently  doAvn.  Then  apply  a  light, 
compressive  dressing. 

VI.  —  Conclusion. 

We  will  now  give  the  scheme  of  treatment  which  you  ought 
to  follow  in  all  cases  of  recent  hip  disease. 

The  diagnosis  being  established,  you  place  your  patient  at 
rest,  in  continuous  extension  or  in  a  plaster,  according  as  the 
case  is  that  of  a  town  child  or  a  hospital  child. 

If  you  employ  the  plaster  apparatus,  construct  it  bivalve 
(fig.  386)  in  such  a  way  as  to  be  able  to  remove  it  easily  at 
each  injection,  so  as  to  give  to  the  thigh,  each  time,  the  slight 
flexion  desired  (fig.  383). 

You  commence  the  injections  after  two  or  three  days  rest. 

You  inject,  as  we  have  said,  the  same  fluids,  in  the  same 
doses  and  at  the  same  intervals  as  if  you  were  treating  a  white 


THE   VALUE    OF    INJECTIONS    INTO    THE    JOINTS 


^97 


swelling  of  the  knee,  or  an  ordinary  cold  a])scess  (v.  Chap.  in). 
Use  a  needle  (N"  2)  bevelled  short,  like  the  needle  used  for 
injection  of  cocaine  in    llie  spine   and  inject  oil,  creosote   and 


Fig.    382.    —    Fixed    points    traced   with  dermographic  chalk;  the    thigh   extended, 
puncture  and  penetrate  until  you  feel  the  bone. 

iodoform  (4  to  10  grammes),  rather  than  naphtol,  camphor  and 
glycerine. 


Fig.  383.  —  The  femur  is  afterwards   put  in  ilexion  at  about  3o°  ;  while  this  move- 
ment is  made,  see   that   the   point  of   the    trocar    does  not   leave  its  contact    with 

the  bone. 


The  nine  or  ten  necessary  injections  take  you  two  months, 
after  which,  for  three  months,  you  make  pressure  with  cotton 


Sq8       HIP-J0I>"T    disease.    THE    USE    OF   ARTICULAR   INJECTIONS 


wool  over  the  articular  region  (always  together  with  continuous 
extension  or  the  plaster). 

This  period  having  passed,  discontinue  the  plaster,  but  you 


Fig.  384.  —  The  incision  allocs  one  to  see  that,  in  tlie  position  of  extension    of  the 
thigh,  the  capsule  is  flattened  over  the  head  and  neck. 


must  wait   four  of  ftve  months  before  allowing  the  patient  to 

ed^ 


get  about.      Then  he  is  cured  ^ 


Fig.  385.  —   In  Qexmg  the  Ibigh,  the  margins  of  tiie  incision  gape  widely,  allowing 
the  space  which  exists  between  the  capsule  and  the  bone  to  be  seen. 

I .  If  this  is  not  so,  that  is,  if  pain  continues  four  months  after  the  injec- 
tions are  stopped,  which  may  sometimes  happen  here  as  in  the  other  cases 
of  white  swellings,  you  would  make  a  second  series  of  injections.  (Consult 
the  note  on  page  499). 


EAIU.V     INJECTIONS    AMLU    HIE    I'UOGNOSIS 


•^99 


So  llial  llie  cure  will  be  oblaiiied  in  ten  iiutiillis  Iruui  llie 
commenrcmenl  of  ihe  treatment  (lo  to  12  months),  instead  of 
the  ilircc  (ir  four  years  ;*j  ref|uircd  b\  the  ordinary  treatment 
without   injections. 

With  the  injections,  tiie  duration  ol'  hip  joint  disease 
will   ihus  be    reduced  by  two   thirds;   but,   above    all,   cure 


Fig.    386.    —    Bivalve   plaster  held    together    hy    bandages  or  by  hooks  and    eyes 

(v.  p.  i56\ 

without  shortening  and  without  lameness  —  complete  cure  — 
w  ill  be  the  rule,  w  bile  with  all  other  treatments  this  result 
w  oukl  be  quite  exceptional. 

Thus  the  history  of  the  treatment  might  be  written  in  three 
lines  :  — 

/*'  period,  that  where  one  used  to  open  the  abscess  :  the 
patients  died  of  hip  joint  disease. 

2""^  period,  that  where  one  punctured  the  abscess  :  the  result 
Avas  the  cure  of  the  hip  disease,  but  at  the  price  of  an  infirmity. 

J"'  period,  that  of  early  intra-articular  injections  :  the 
hip  disease  is  cured,  cured  quickly,  without  lameness  and  without 
defect  of  any  kind  (see  Journal  des  Practiciens,  i\  march  1908; 
Traitement  de  la  Coxalgie,  conference  faite  a  I'hopital  Beaujon 
[service  du  professeur  Robin  ,  par  F.  Calot). 


400       6*''    VARIETY.    ANKYLOSIS,    LAMENESS    AND    SHORTENING 


6"^  VARIETY.  HIP  JOINT    CASES  «  CURED    .,  BUT   WITH  A  DEFECT. 
(SHORTENING,  ANKYLOSIS,  LUXATION  . 

I  wish  to  speak  here  of  those  cases  of  hip  joint  disease 
cured,  or  apparently  cured  for  one  or  several  years,  which  come 
to  you,  or  come  back  to  you,  for  some 
functional  defect  (fig.  887  and  889). 

The  parents  complain  that  the  child  is 
more  or  less  lame,  that  the  limb  is  shor- 
tened and  is  still  becoming  shorter,  that  the 
hack  is  deformed,  at  the  same  time  that  the 
loins  are  becoming  hollow ;  or  simply  that 
the  hip  is  stiff,  which  causes  a  difficulty  in 
sitting  down  and  in  putting  on  the  shoes. 

They  come  to  ask  you  if  it  is  possible 
to  efface  these  functional  defects  or  ar  least 
to  prevent  them  becoming  Avorse. 

Your  reply  should  be  prompted  by  the 
two  following  principles  : 

1**.  If  there  is  simply  stiffness  of 
the  hip,  nothing  must  be  done. 

2°''.  If  there  is  lameness  and  shorte- 
ning, or  dorsal  deformity,  one  can  and  one 
ought  to  obliterate  as  much  of  this  lameness  and  shor- 
tening as  is  caused  by  the  deformity  of  the  hip  joint. 


Fig.  387.  —  Vicious  aak\lo- 
sis  ;  flexion,  adduction  aad 
internal  rotation. 


Fig.    388.   Vicious  ankylosis  ;  hollowing  very  marked. 

The    deformity   removed,  do    not    look    for    mobility,  but 
endeavour  to  produce  an  ankylosis  in  a  good  position. 

I  will  explain  myself  on  the  two  rules  I  have  just  laid  down. 
I'*.  You  Avill  not  interfere  in  order  to  «  loosen  w  the  hip  joint. 


IIIP-JOINT    DISEASE     :     MEASURE    OF    TOTAL    SlIORTEiNlNG         /jO  r 


lumbar 
hollow 

ischium 


spines 


In  Tact,  it  is  cilhcr  a  question  of  hip  disease  without  short- 
ening —  (see  further  back,  the  hip  diseases  of  the  first  variety) 
—  and  then  you  will  not  touch  it,  in  virtue  of  the  priino  non 
nocerc;  for,  not  only  would  you  not  have  more  than  one  chance 
in  ten  of  re-establishing  the  movements,  but  you  Avould  run  too 
great  a  risk,  in  interfering,  of  aggravating  the  patient's  condition. 

Or  it  is  a  question  of  hip  disease  with  shortening  —  (see 
further  back,  hip  diseases  of  the 
second,  third,  fourth  varieties)  —  and 
then  it  would  be  rendering  a  very 
poor  service  to  the  patient  to  do 
aAvay  with  the  stifTness  of  his  hip  joint 
(admitting  that  it  were  possible  to 
succeed  in  this  without  danger  to  him). 
As  a  matter  of  fact,  these  patients 
would  not  walk  so  Avell  afterAvards  as 
before.  It  is  to  their  interest  to  have 
the  hip  stiff;  this  is  so  true  that  you 
must,  in  the  case  of  persons  with  hip 
disease  in  whom  the  joint  is  movea- 
ble and  there  is  marked  lameness, 
endeavour  to  stiffen  the  joint  in  order 
to  lessen  the  lameness  (which  can  be 
done  by  wearing  an  immoveable  appa- 
ratus over  a  long  period). 


2"'*.    Principle  :    in  lameness  due 


Fig.  389.  —  In  oilier  to  learn 
the  exact  functional  shortenino-. 
one  ought  to  efface  the  lumbar 
hollow  and  place  the  two  iliac 
■spines  on  the  same  level  ;  this, 
one  does  with  Ihe  patient 
upright.  The  shortening  is 
equal  to  ihe  difference  of  level 
of  Ihe  two  heels. 


to  shortening,  one  will  do  away  wdth 

the   amount  of  it  caused   by  the  deformity. 


But  what   is   this 


amount.^     That  is  what  Ave  are  going  to  determine. 
A.  —  Shortening.     Its  Causes  or  Factors 

Very  marked  shortenings  are  due  to  tAvo  principal  factors  : 

1.  A  deformity  of  the  hip  joint. 

2.  Wearing  away  of  the  extremities  of  the  diseased   bones 
and  atrophy  of  the  skeleton  of  the  Avhole  hmb. 

Calot.   —  Indispensable  orthopedics.  26 


402 


APPARENT  SHORTENING  AND  REAL  SHORTENING 


Against  the  first  factor  of  shortening  we  can  do  much. 
Against  the  second  we  can  do  nothing ^      We  can  only  hide 
it  by  causing  a  high  heeled  boot  to  be  worn. 

Method   of   ascertaining   the   total  shortening   and  the  amount 

of  it  due  to  the  deformity  (fig.  889  to  8961. 

In  order  to   bring    the  foot  of  the   affected   leg  as  near  as 
possible  to  the  other,  the  patient  hollows  and  deforms  his  back. 


Fig.  390.  —  Here  the  shortening^  is  measured  with  Ihe  patient  lying  down.  To  make 
the  hollow  disappear  ones  has  been  obliged  to  give  to  the  knee  this  marked  degree 
of  ilexion.     The  total  shortening  is  equal  to  the  distance  which  separates  the  heels. 

By  this  artifice,  he  will  have  less  apparent  shortening 


Fig.  391.  —  An  unlikely  deformity.  The  patient  walks  by  supporting  himself  on 
his  hands.  The  shortening  equals  the  distance  bet\Yeen  the  heels  and  even  more, 
for  one  can  see  that  the  hollowing  is  not  entirely  done  away  with  and  that  one 
would  have,  in  order  to  obliterate  it,  to  raise  the  knee  still  more. 


and   perhaps   less  lameness ;   but  he   Avill  have  in  addition   an 
I.  Except  as  preventive,  by  injections   (v.  p.  38^'. 


mi>  uisi:.vsE 


la.XGTlONAL 


SlIOUTEMNG 


/|o3 


nnsig:hllY  dorsal  dcrormity.  ^^llicll  \\i\\  not  be  any  bcllcr  than 

a  degree  more  of  lameness,  especially  in  the  case  of  a  young  girl. 

To  demonstrate  the  real  shortening,  ihe  total  shortening 


interline    o 
the  knee 


malleolu 


Fig.  892.  —  Measurement  of  the  limb.  — 
Measure  from  the  centre  of  Nelaton's  line 
lo  the  external  margin  of  the  sole  of  the 
foot  (passing  by  the  point  of  the  external 
malleolus) . 


iliac  spine 


lumbar  hollow 


Interline        tou-         } 
cliing  the  top 
of  the  bone 


bi  malleolar 
line 


Fig.  898.  —  Measurement  of  the 
front.  (Compare  the  measure- 
ments obtained  from  the  two 
limbs). 


of  the  lower  limb,  you  ought  to  begin  by  placing  the  back 
quite  straight  and,  in  order  lo  do  so,  you  proceed  to  flex  and 
carry  inwards  the  affected  thigh  until  the  lumbar  hollow  is 
effaced,  until  the  "  loins  "  touch  the  table  and  until  the  two 
iliac  spines  are  at  the  same  level  (at  the  same  perpendicular  to 
the  median  axis  of  the  body).  This  done,  you  bring  the  affec- 
ted heel  against  the  sound  calf,   and  measure  from  the  point  ol 


4o4  SHORTENING    :     THE    PART    PLAYED   BY   DEVIATION 

contact  to  the  sound  heel  (see  fig.  890  and  Sgi);  this  distance 
gives  you  the  total  shortening  \ 

What  is  the  share  of  each  of  the  t^vo  factors  :  deviation 
and  wearing  away? 

It  is  easy  to  calculate. 

Measure  the  length  of  the  affected  limb  starting  from  the 
centre  of  Nekton's  line  (I  say  from  Nelaton's  line  and  not  from 
the  upper  border  of  the   displaced  trochanter);   measure  from 


Fig.  Sgi-SgS.  —  Method  of  measuring  the  share  which  is  due  to  wasting  of  the  bone  ; 
—  the  wasting  is  equal  to  the  distance  which  separates  the  two  horizontals  (tro- 
chanter and  centre  of  Nelaton's  line). 

this  line  doAvn  to  the  external  border  of  the  sole  of  the  foot 
(fig.  392).  Take  the  same  measurement  on  the  sound  side, 
from  Nelaton's  line  to  the  sole  of  the  foot. 

Compare  the  measurements  of  the  two  sides. 

a.  Wearing  away  of  the  skeleton.  The  difference  be- 
tween the  two  sides  represents  the  share  of  the  factor  which 
comprises  the  Avasting  of  the  articular  extremities  and  the  atro- 
phy of  the  skeleton  of  the  whole   limb.      The  wasting  of  the 

I .  Measured  thus,  one  sometimes  calls  the  shortening  functional,  in 
contradistinction  to  the  real  shortening  which  should  be  ' '  the  loss  of  svibslance  " 
of  the  bones  in  their  length;  this  distinction  is  an  error,  or  at  least  demands 
an  explanation;  the  functional  shortening  which  is,  for  example,  of  i5  cm., 
is  the  real  shortening,  in  the  sense  that  the  patient  is  really  as  lame  as  if  he 
had  a  shortening  of  i5  cm.,  and  if  one  does  not  remedy  it,  the  patient  will 
remain  shortened  all  his  life  just  as  if  he  had  really  lost  i5  cm.  of  the  length 
of  his  limb. 


AVIIAT    IT    IS    POSSIBLE    TO    DO    AGAINST    SHORTENING  liOO 

extremities  alone  is  equal  lo  llic  distance  from  the  superior 
border  of  llie  trochanter  above  tbe  centre  of  Nekton's  line 
(v.  %.  39 'i,  395). 

b.  Deformity.  —  The  remainder  of  the  total  sliortening 
will  be  Ihe  share  of  the  deformity. 

Let  US  suppose  the  total  shortening  to  be  1 5  cm.  (which  it 
frequently  is)  and  that  you  have  found,  on  measurement  in  the 
wav  we  have  mentioned,  a  difference  of  3  cm.  between  tho  two 


Fis.  396.  —  Estimation  of  wearing  away  and  atropiiy  in  the  length  of  the  bones. 
The  small  horse-shoe  indicates  the  outline  of  the  troch^inter  :  the  distance  from  the 
trochanter  to  Nelaton's  line  indicates  the -wasting.  Fron  the  trochanter  to  the  point 
of  the  patella  (interline  of  the  knee-joint;  and  from  that  interline  to  the  external 
malleolus,  one  has  the  measure  of  the  length  of  the  bones;  compare  with  the  sound 
side  'the  same  fixed  points). 

lower  limbs.  To  the  deviation  will  belong  in  this  case,  i5  cm. 
less  3,  that  is  12  cm. 

You  will  be  able  to  promise  the  parents  that  you  will  do 
away  Avith  the  12  cm.  —  that  is,  four-fifths  of  the  shortening 
—  by  your  treatment. 

Instead  of  actually  10  cm.,  you  Avill  tell  them  that  the 
child  will  not  have  more  than  3  cm.  of  shortening.  And  with 
only  3  cm.  and  with  a  hip  joint  solidly  fixed  in  good  position, 
he  Avill  not  be  noticeably  lame. 

The  Reason  for  Interfering  with  Shortening. 

In  what  case  would  it  be  well  to  interfere :'  —  At  what 
moment:*  and  howP 

I".  AVe  have  said  that  much  can  be  done  against  deformity. 


4o6     ANKYLOSIS.        SIMPLE    STRAIGHTENING    RATHER    THAN    OSTEOTOMY 

Is  this  a  sufficient  reason  for  submitting  the  cliikl  to  an 
interference  every  time  there  is  a  deformity?  No.  Unless  the 
result  is  worth  it.  So  I  advise  you  to  do  nothing,  or  to  use  only 
shght  means  —  traction  at  night  time,  weights  on  the  but- 
tocks, etc.  (see  fig.  85o  and  855),  in  those  cases  where 
there  is  less  than  4  or  5  cm.  attributable  to  the  deformity,  and 
if,  moreover,  this  deformity  is  not  increasing.  To  make  sure 
of  it,  take    the  exact  measurements  every  three  or  six  months. 

On  the  other  hand,  it  Avould  be  necessary  to  interfere  each 
time  that  at  least  5  to  6  cm.  are  due  to  deviation,  especially 
if  this  were  increasing.  And  it  happens  very  frequently  that 
deviation  is  responsible  for  more  than  5  or  6  and  even  lo  cm. 
and  that  it  has  a  certain  tendency  to  increase. 

How  to  interfere,  that  is,  by  what  procedure?  That  will 
depend  on  the  degree  of  stiffness  of  the  hip  joint  and  the  variety 
of  the   ankylosis  —  complete,  osseous ;  or   incomplete,  fibrous. 

Direct  examination,  in  revealing  lo  you  very  distinct  mo- 
vements, enables  you  to  make  a  diagnosis  easily  in  the  great 
number  of  cases. 

In  doubtful  cases,  when  you  do  not  perceive  distinct  move- 
ment in  the  femur  (after  having  fixed  the  pelvis)  have  recourse 
to  X  rays,  which  will  shew  you  a  continuity  between  the  two 
bones.  In  default  of  radiography,  administer  a  few  drops  of 
chloroform  to  make  a  rapid  examination  of  the  hip,  and  make 
certain  whether  there  is  movement  or  not.  I  can  assure  you  that 
you  Avill  nearly  always  hnd,  in  true  coxitis,  afew  movements, 
even  in  the  cases  labelled  "  complete  ankylosis  of  the  hip-joint". 

B.  —  Ankylosis  in  Hip  Joint  Disease 

P'.   Case  (frequent).  —  Incomplete  ankylosis. 

You  have  perceived  (with  or  Avilhout  chloroform)  very  dis- 
tinct movement;  you  will  make  a  simple  redressment  (without 
tenotomy  if  you  are  not  a  surgeon  —  with  or  without  tenotomy 
if  you  are  a  surgeon). 

1^'^.  Case  (rare).  —  Complete  ankylosis. 


THE    TREATMENT    OF    ANKYLOSIS   IN    1111'  JOINT    DISEASE 


'107 


There  are  no  distinct  movements,  cmmi  under  chlorororni ; 
do  not  persist,  lor,  in  pcrslsling  for  lo  minutes,  you  might 
provoke  them  very  often,  because  you  may  happen  to  separate 
the  two  A\ elded  articular  extremities;  you  may  cause  also  a 
great  traumatism;  do  not  do  it;  it  would  he  heller  to  consider 
it  clinically  as  one  of  those  cases  n| 
complete  ankylosis,  Avhere  there  is  not 
immediately,  under  chloroform,  any 
appreciable  movement. 

For  such  cases,  you  Avill  perform  a 
supra-trochanteric  osteotomy  (linear 
and  sub  -  cutaneous)  or  an  inter- 
trochanteric, to  be  further  away  from 
the  old  focus. 

I  do  not  Avish  to  leave  you  igno- 
rant of  the  fact  that  surgeons  prefer 
osteotomy,  even  for  incomplete  ankylo- 
sis, to  simple  redressment,  because, 
say  they,  redressment,  by  disturbing  the 
seat  of  the  old  tuberculous  focus,  is 
sure  to  predispose  to  a  revival  of  the 
tuberculosis  much  more  than  osteo- 
tomy, which  acts  on  a  point  far  re- 
moved from  the  focus. 

This  objection  has  scarcely  more 
than  a  theoretical  value,  especially  if 
one  does  not  carry  out  the  redressment  until  the  tuberculosis 
is  quite  cured  and  the  patient's  general  condition  is  good ;  it 
might  be  necessary  to  Avait  for  one  or  two  years  on  that  account. 
With  a  redressment  done  at  this  moment,  methodically,  in 
two  stages  if  you  like,  you  would  not  run  any  more  appre- 
ciable risks  of  re-awakening  tuberculosis  than  by  an  osteotomy. 
On  the  whole,  simple  redressment  remains,  in  every  way, 
more  certainly  benign  than  osteotomy.  With  redressment  you 
would    have   no   operative   complications,    Avhilst    you    might 


Fia;.   Sqy.  —  Luxation. 


4o8  LUXATIOiX    OF   THE    FEMUR   IN    HIP    DISEASE 

perhaps  have  them  with  osteotomy :  immediate  infection  of  the 
small  AYOund,  or  secondary  infection  of  the  periosteal  ha3matoma. 
^or  this  reason  I  do  not  hesitate  to  recommend  to  you, 
practitioners  and  non-specialists,  redressment  rather  than  osteo- 
tomy for  all  cases  Avhere  some  movement  persists. 

C.  —  Luxation  of  the  femur  in  hip  disease. 

AA'e  ought  to  speak  here  of  complete  luxations  of  the  femur, 
which  we  must  guard  against  confounding  with  a  simple 
over-riding  of  the  head  in  the  acetabulum  made  larger  by 
Avearing  of  the  bone ;  over-riding  of  this  kind  is  as  frequent  as 
luxation  is  rare  (fig.  897  and  /i7i). 

You  will  without  doubt  never  see  luxation  at  the  onset  of 
hip  disease  (I  have  seen  only  one  case  in  17  years)  and,  if  you 
do  see  it,  you  will  reduce  it  without  chloroform  by  the  ma- 
noeuvres one  carries  out  for  congenital  dislocation  of  the  hip 
(v.  chap.  xiv). 

But  you  Avill  have  occasion  to  see  luxations  following  hip 
disease  in  spite  of  the  fact  that  complete  dislocation ,  as  the  last  stage 
of  the  disease,  is  exceptional  if  the  case  has  been  looked  after. 

The  diagnosis  is  easy  to  establish  by  radiography.  In  the 
absence  of  the  X  rays,  it  is  very  delicate,  except  in  the  cases 
where,  by  palpation,  one  can  distinctly  feel  the  head  of  the 
femur  in  the  buttock;  but  this  is  rare,  because  the  surroun- 
ding tissues  are  hardened,  and  especially  because  the  head  of 
the  femur  and  even  the  neck  are  more  or  less  eroded  or  des- 
troyed in  these  varieties  of  hip  disease. 

To  make  the  diagnosis  in  these  cases,  one  may  admit  that, 
as  a  general  rule,  if  the  trochanter  is  more  than  4  cm.  above 
Nekton's  line,  there  is  a  true  luxation  of  the  femur;  below 
(i  cm.  it  is  a  question  rather  of  a  simple  over-riding  of  the 
head  in  the  acetabulum,  without  the  head  having  escaped  from 
the  enlarged  cavity. 

The  treatment  of  pathological  luxations  of  the  femur  is 
very  difficult,  but  one  is  not  completely  helpless,  far  from  it. 


DOUBLE    HIP-JOINT    DISEASE.     ITS    TREATMENT  ^09 

^^'illlOul  recUoniny  llial  one  can  always  corrccl  the 
flexion  and  adduction  Avhich  generally  accompany  dislocation, 
one  may  yet  manage  to  correct  it,  cither  by  c(  reducing  »  the 
head,  if  it  is  in  good  condition,  Avhich  is  rare,  or,  when  the 
head  is  destroyed,  by  supporting  in  the  bottom  of  the  acetabu- 
lum the  upper  extremity  of  the  trochanter,  which  is  always 
preserved  (v.  p.  4 60). 

HIP-JOINT  DISEASE  ASSOCIATED  WITH   OTHER 
TUBERCULOSES 

a.  Double  Hip-Joint  Disease. 

Double  coxitis  is  rare ;  fortunately  so,  because  it  is  very 
grave  from  an  or thopoedic  point  ofvicAV. 

Double  coxitis  would  not  be  so  formidable  if  the  patient 
would  come  at  the  very  beginning,  and  be  treated  Avith  early 
articular  injections;  —  but  that  is  scarcely  ever  the  case,  and 
then  the  disease  becomes  aggravated  rapidly;  the  bilaterality 
of  the  coxitis  shews  already  that  serious  tuberculosis  is  at  work, 
and  serious  tuberculosis  does  not  remain  at  the  first  degree, 
neither  on  one  or  the  other  side.  It  leads  nearly  always  to 
deformity  and  to   abscesses  (vide  second  and  third    varieties). 

And  so  we  are  ((  caught  in  a  dilemma  »  ;  either  the  limbs 
are  not  sufficiently  immobilised  in  which  case  the  deformity 
continues  to  progress,  or  they  are  placed  in  a  large  plaster, 
and  a  double  ankylosis  will  result.  But,  if  ankylosis  of  one 
hip  only  does  not  prevent  the  patient  Avalking,  bilateral  anky- 
losis is  disastrous  for  walking,  for  sitting  down  or  bending, 
in  a  AAord,  for  all  the  natural  and  physiological  functions. 

\ou  see  that,  whatever  is  done,  the  orthopoedic  prognosis 
of  double  coxitis  remains  bad.  Further,  abscesses  are  of  fre- 
quent occurrence,  they  are  more  grave,  more  liable  to  open 
than  in  simple  coxitis  and  there  is  generally  a  persisting 
fistula,  the  evil  consequences  of  Avhich  you  know. 

What  is  the  course  to  take? 

When  you  chance  to  see  a  double  coxitis  at  its  onset,  do 


4io 


HIP    DISEASE    AIXD    POTT  S    DISEASE 


not  neglect  to  endeavour  to  stop  the  evolution  of  tuberculosis 
(by  intraarticular  injections). 

As  to  orthopcedic  treatment  :  rest  on  a  frame  with  conti- 
nuous extension  well  looked   after.      And.   in   a   general  way, 

prefer  extension  to  a  plas- 
ter, because  extension  safe- 
guards the  mobility  of  the  joint. 
If  rotation  of  the  limb, 
exists  outwards  or  inw'ards, 
meet  it  by  the  means  sheAvn 
in  the  figures  852  to  854- 

But  extension  is  not  always 
sufficient  to  prevent  deformity 
being  produced  or  to  sooth 
very  troublesome  pain .  It  will 
then  be  necessary  to  have  re- 
course to  the  plaster  for  a  while. 
But  return  to  the  extension  as 
soon  as  possible. 

What  can  be  done  against 
the  deformity  and  stiffness 
already  produced  .^^ 

If  the  deformity  and  stiff- 
ness are  next  to  nothing, 
leave  them  alone. 

If  the  deformity  is  very  mar- 
ked (more  than  3o°)  correct  it 
gently,  supporting  Avith  a  plas- 
ter for  two  months,  then  go  on  with  the  continuous  extension. 
In  the  case  of  stiffness,  if  there  exist  at  the  same  time  a 
bad   position,  correct  it  (you  knoAv   how)  without  troubling 
to  restore  mobility. 

If  the  hip  joints  are  stiff  but  in  a  good  position,  do  not 
touch  them  :  not  that  there  are  no  operations  proposed  for  mo- 
bilising the  joints,  there  are  too  many  I 


Fig.  398.  —  Coxitis  and  middle  dorsal  Pott's 
disease.  —  The  plaster  is  provided  with  a 
dorsal  opening  for  compression  of  the 
gibbosity,  and  a  pre-inguinal  one  for 
articular  injections  (or  for  the  treatment 
of  an  abscess  of  the  hip  joint). 


HIP-JOINT    DISEASE     :     THE    TECHNIQUE    OF    THE    TREATMENT        '|  I  I 

Do  not  |iorloi-m  any  of  these  because,  \villi  llie  besl  of 
them,  Mill  will  inn  at  least  nine  chances  out  of  ten  of  douig 
more  harm  than  ijood. 

b.  Coxitis  with  Potts  Disease    fig.  398;. 

The  prognosis  for  good  walking  is  very  poor,  especially 
Avhen  the  Pott's  disease  is  situated  in  the  lower  part  of  the 
vertebral  column  :  which  one  can  understand,  because  the 
Pott's  disease  causing  an  ankylosis  of  the  lumbar  spine  and 
the  Hip  disease  leaving  behind  it  so  often  a  rigid  hip,  the 
child  w  ill  be  helpless  -with  this  double  ankylosis. 

The  treatment.  —  One  encloses  in  a  single  plaster  the  trunk 
and  the  whole  of  the  lower  limb. 

If  the  large  plaster  is  badly  tolerated,  take  ofT  the  leg  por- 
tion, and  hrst  endeavour  especially  to  cure  the  Pott's  disease  by 
the  ordinary  treatment  (see  Pott's  disease);  for  the  hip  disease, 
make  simply  continuous  extension  (at  the  same  time  articular 
injections).  Afterwards,  Avhen  the  Pott's  disease  has  been  cured, 
you  will  complete,  if  need  be,  the  correction  of  the  hip. 

c.  Hip  Joint  Disease  with  White  Swelling  of  the  Knee 
on  the  same  side. 

One  treats  the  two  diseases  at  the  same  time  by  making 
either  extension,  or  a  large  bivalve  plaster,  and  one  endeavours 
to  preserve  some  movements  as  much  as  one  can  (early  injections). 

d.    Hip   Disease    co-existing   with   Multiple   Bacillary  Infections. 

See  Chap,  xx,  On  multiple  tuberculoses. 

II.  —  2-'.  PART  OF  THE  TREATMENT.    TECHXIQUE. 

The  technique  of  the  treatment  of  Hip  Disease  comprises  : 

I''.  The  manner  of  ensuring  rest  for  the  hip  in  the  lying  posi- 
tion, on  a  frame; 

2°''.   Continuous  extension ; 

3"'.  The  Plaster  apparatus  ; 

4'''.  Rediessment  of  the  hip  (simple  redressment,  with  or 
■without  tenotomy  or  osteotomv); 


4t2 


HIP-JOI>'T    DISEASE     :     TECHNIQUE    OF    TREATMENT 


5"".   Treatment  of  the  abscess  of  hip  disease  ; 
G"".   Drainage  and  resection  of  the  hip  joint. 


REST  ON  A  FRAME 


Does  it  not  seem  useless  to  devote  a  chapter  upon  the  way 
to  ensure  rest  for  the  hip  in  the  recumhent  posture  ? 


Fig.  Sgg.  —  Our  frame.  —  An  ordinary  frame  arranged  with  a  median  opening  on  a 
level  with  the  seat  :  the  opening  is  closed  at  ordinary   times  by  a  tampon  (T). 

I  do  not  think  so. 

It  seems  sufficient,  docs  it  not,  to  place  the  patient  on  a 
bed  :*  Yes,  doubtless,  if  the  mattress 
is  hard,  even,  and  quite  flat;  and  if 
the  bed  can  be  easily  carried  out  of 
doors,  to  allow  of  the  child  passing 
I     the  whole  day  in  the  open  air. 

It  is  more  practical  to  place  the 
patient  on  an  ordinary  board  well 
stuffed  and  moveable ;  or  better  still  on 
a  wooden  frame  padded  with  horse- 
hair, provided  on  each  side  with  stops 
for  the  straps  destined  to  restrain  the 
body  ;  the  straps  are  fixed  at  one  side 
and  are  buckled  at  the  other  (fig.  Sgg). 
At  the  two  extremities  of  the  board 
or  of  the  frame  are  two  iron  handles 
to  carry  the  child  into  the  open  air, 
either  into  the  garden  on  two  chairs,  or  on  a  small  carriage. 
The  cushioned  board  or  frame  may  be  made  anywhere,  "iour 
cabinet  maker  or  upholsterer  will  make  it  for  you. 


Fig.  tioo.  —  Our  frame.  —  An 
utensil  in  place, seen  from  above 
—  B.  cushioned  tampon  which 
serves  to  take  the  place  of  the 
utensil  when  the  latter  is  not 
required. 


IIEST     I  I'ON    A    rUAME 


^'.i3 


These  verv  simple   means  ai-e  excellent.      But   lor  the  cases 


lMl;^^l::i:h;i:t!i:l|(:;:ri>v;:;:i::n::::.-::^n:r-''''l''l 


W 


Fig.   ioi.   —  Our  frame  seen  from  Ijelow   «illi  its  slide. 

Avhere  absolutely  perfect   rest  for  the  hip  is  necessary,  I  object 
to  them,  as  they  allow   the   child  to   alter  his  position  and  do 


Fig.   402.  . —  Our  «  frame  ».  —  The  strap  for  the  legs  is  fixed  by  its  middle  part  to 
embrace  the  limb  in  a  buckle. 

not  permit  of  his  using  the  bed-pan  without  inevitably  causing 
an  unnecessary  jerk  and  displacement  of  the  hip. 

To  do  away  with  these  avoidable  movements,  I  have  had 
frames  constructed  with  a  large  median  opening,  made  on  a 
level  with  the  seat  (fig.  4oo).  When  not  wanted,  the  median 
opening  is  fdled  exactly  with  a  cushion,  evenly  rounded, 
pushed  in  and  supported  by  a  board  sliding  in  grooves  beneath 
the  frame  (iig.  4oi). 

At  the  moment  of  using  the  bed-pan,  you  draw  the  board, 
take  out  the  cushion  and  slide  in  its"  place  an  utensil  of  suitable 


4l4    HIP-JOI.\T    DISEASE    :    SEGUROG    THE    PATIENT    ON    A    "    CADRE 


size  and  dimensions,  which  is  thus  adapted  to  the  opening; 
one  draAVS  the  board  underneath  to  keep  the  utensil  in  place, 
in  the  same  way  as  the  cushion,  for  the  necessary  length  of  time. 

To  be  assured  more  exactly  of  the  fixation  of  the  legs, 
one  can  arrange  the  straps  for  the  legs  and  knees  in  a  double 
loop  for  each  limb  (fig.  402  and  4o3). 

The  fixation  of  the  trunk  is  effected  by  two  broad  straps, 


Fig.  /io3.  —  Child  on  his  frame.  One  sees  tlie  two  straps  on  the  legs  and  thighs, 
tixed  by  their  middle  portion  and  embracing  the  limbs  in  a  double  loop.  Counter- 
extension  is  obtained  by  the  weight  of  the  body,  provided  that  the  lower  end  of  the 
frame  is  raised  bv  one  or  two  bricks  placed  under  the  feet  of  the  wooden  supports. 

or  by  a  waistcoat  of  ticking  passed  over  the  shirt,  a  waistcoat 
of  Avhich  the  two  shoulders  and  lower  edges  are  fixed,  by  lea- 
thern straps  to  the  sides  of  the  frame. 

In  Bonnet's  splint,  there  is  a  similar  method  of  fixation ; 
but  Bonnet's  splint  is  dear  and  not  easily  obtainable.  It  has 
another  more  serious  objection  :  the  Bonnet  splint  is  generally 
badly  constructed,  is  not  sufficiently  even  and  flat;  it  is  easily 
depressed  and  put  out  of  shape,  and  masks  the  deformity 
which  progresses  unobserved,  so  that  '-one  very  often  removes 
from  a  Bonnet's  splint  a  deformed  child  ". 

I  like  much  belter  to  employ  the  ordinary  frame  as  I  have 
modified  it.     It  has  the  same  advantages  as  the  sjDlint  without 


I-1\ATI0N    Ol-    Tilt:    TWO    LIMBS  /|  1 5 

lia\lni:  ils  inconveniences:  it  can  be  made  hy  any  cabinet  maker 
at  a  ver\  low  price;  il  may  1)C  completed  by  a  hard  and  even 
mattress  made  by  an  upholsterer  orevenl)\  ihe  child's  mother. 
The  mallress  ought  lobe  a  liltlc  thicker  at  the  level  of  Ihe  seal,  to 
support  the  pelvis  raised  up  and  to  prevent  hollowing  of  ihe  back. 

One  can  adapt  to  the  lower  exlremily  of  ihe  frame  trans- 
verse rods,  on  which,  in  a  groove  in  place  of  a  pulley,  you 
can  pass  a  cord  for  continuous  extension  (lig.  /io:^). 

I  prefer  the  two  limbs  to  be  supported  for  tw  o  reasons ; 
the  hrst  is  llial  the  sound  limb  being  free  might,  by  ils  exagge- 
rated movements,  impart  slight  shocks  to  the  pelvis;  the  second 
is  that  it  is  important,  for  the  future,  thai  the  two  limbs  may 
be  placed  under  the  same  regime  of  absolute  rest  for  the  dura- 
tion of  the  disease,  especially  Avhen  one  is  trying  to  obtain  a 
perfect  cure,  as  is  here  the  case. 

As  a  matter  of  fact,  the  cure  could  not  be  perfect  if  one  of 
ihe  limbs  —  the  affected  one  —  were  forcibly  immobilised  — 
whilst  the  other  —  the  sound  one  —  could  move  about  unre- 
strained in  the  bed.  After  a  year  or  two  of  this  regime  the 
restrained  leg  would  waste,  whilst  the  free  leg  would  very 
often  have  become  hypertrophied. 

When  the  patient  begins  to  Avalk  again  he  will  not  be  able 
to  do  so  symmetrically  if  one  leg  is  feeble  and  the  other  very 
strong.  If  the  two  legs  are  equally  feeble,  on  the  contrary, 
they  Avill  demand  the  same  effort;  they  Avill  resume  symme- 
trically and  simultaneously  their  power  and  iheir  usefulness. 
The  legs  being  more  equal,  Avalking  Avill  be  more  regular  and 
the  cure  more  perfect. 

So  as  to  omit  nothing,  we  may  add  that  the  children  lying 
doAvn  are  generally  clothed  in  long  blouses  of  flannel,  open 
behind  from  top  to  bottom. 

At  meal  times,  one  allows  the  child  to  raise  his  head 
slightly  Avhilst  his  shoulders  are  steadied  by   a   small   cushion. 

To  entertain  the  children,  Ave  promenade  them  once  or 
tAvice  a  day  in  small  carriages,  on  a  flat  field,  to  avoid  shaking. 


4i6 


HIP- JOINT   DISEASE    :     CONTINUOUS    EXTENSION 


About  every  six  Aveeks,  one  takes  the  child  from  his  frame 
or  out  of  his  spUnt,  placing  him  on  an  ordinary  table,  which 
alloAYS  one  to  verify  the  position  and  the  condition  of  the  joint. 
The  mother  will  avail  herself  of  the  opportunity  and  make  the 


Fig.  Aoi.  —  Legging  made  of  ticking   or  of  leather  for  continuous  extension. 

complete  toilet  of  the  little  patient.      This  monthly  examination 
helps  to  prevent  the  hip  joint  becoming  stiff. 

2.  CONTINUOUS-EXTENSION 

You  knoAv  alreadv  well  enoush  how  to   make  continuous 


Fig.  4o5.  —  Extemporised  apparatus  for  continuous  extension.  The  foot  is  bandaged 
up" to  the  malleoli.  A  strip  is  placed  in  stirrup  fashion  under  the  sole;  the  two 
ends  of  this  strip  are  applied  to  the  limb  up  to  the  groin. 

extension  for  fractures  of  the  thigh ;  you  have  only  to  apply  it 
in  the  treatment  of  hip  disease. 

There  are  manv  Avavs  of  hxinof  to  the  affected  limb  the  lines 


Fig  4oG.  —  The  two  tails  of  the  stirrup  are  covered  to  above  the  knee.  They  are 
afterwards  turned  on  each  side  of  the  Hmb  and  the  bandage  is  rolled  downwards 
over  them  to  the  malleoli. 

which  sustain   the  extension  Aveights.     If  you  have  a  method 
you  are  familiar  Avith,  keep  to  it. 


TECIIMQUI-:    <>l'    CONTIMOLS    KXTP.NSION 


^•>7 


11  voii  air  iisclI  I(^  sli'i|is  i)(  (liacli  \  Inn .  all  is  well;  makr 
ihcMi  run  up  In  the  iipiicr  lliinl  nf  ihc  lliiiih  so  thai  lliey  act 
on  lliat  and  nol  on  ihe  ley. 

If  y oil  liavo  no  melliod  you  prefer,  this  is  wlial  I  advise, 
because  it  nia\  he  used  everywhere  and  the  parents  are  in  a 
general  way  ahle  lo  I'mk  well  afler  \\\r  cliiM  In  your  absence, 


Fig.  ffO-.  —  Contiauous  eitsnsion.  —  The  patient  is  put  to  bed  and  kept  tbere 
with  our  extension  apparatus.  Counter-extension  is  secured  by  the  raising  (at  llie 
lower  end    of  the  chassis  upon  which  the  splint  rests. 

a  necessary  condition  in  order  that  the  extension  may  be   pro- 
perly continued. 

Extension 

a)  Extension.  —  Have  made  in  ticking,  or  better  still  in  soft 
leather,  a  long  stocking  which  reaches  to  the  upper  third  of 
the  thigh,  laced  in  front,  with  eyelets,  and  a  u  tongue  »  as 
used  Avith  boots  (fig.  4o4 )-  There  should  be  no  seam  at  the  heel ; 
you  may  even  make  an  opening  to  avoid  any  sore  at  that  point. 
From  the  calf  of  the  stocking  starts,  on  each  side,  a  leathern 
thong,  Avhich  is  kept  a^vay  from  the  malleoli,  in  order  to 
avoid  all  pressure,  by  means  of  a  Avooden  rod  placed  transver- 
sely, slightly  longer  than  the  breadth  of  the  sole  of  the  foot,. 

G.VLOT.  —  Indispensable  orthopedics.  27 


4l8    HIP   JOINT    DISEASE    :     TECHNIQUE   OF    CONTINUOUS    EXTENSION 


and  at  each  extremity  of  Avhich  is  found  a  hook  passing  through 
a  hole  at  the  extremity  of  each  leathern  thong. 

At  the  middle  part  of  the  rod  is  another  hook  to  Avhich  the 
cord  for  carrying  the  Aveight  is  fixed ;  this  cord  passes  over  a 
pulley,  or,  in  default  of  a  pulley,  over  the  transverse  har  at 
the  foot  of  the  bed  or  of  the  frame;  or  even  through  a  hole 
cut  out  of  the  end  board  of  the  frame  or  Avooden  bed.  Nothing 
is  more  easy  to  adapt.     At  the  extremity  of  the  cord  one  fixes 


Fig.  4o8.  —  Counter-extension  is  verv  easilv  elTeeted  by  placing  bricks  under  the  feet 
of  the  fore  part  of  the  bed  or  of  the  chassis  which  supports  the  frame. 


leaden  Aveights   or  sand-bags,   weighing 


3,  4  kilogrammes 
according  to  the  age  of  the  child  and  the  result  Avhich  is  aimed 
at.  If  you  are  correcting  a  deformity,  you  increase  the  weight 
up  to  6,  8,   ID  kilogrammes. 

The  stocking  should  be  laced  more  or  less  tightly,  in  any 
case  so  firmly  that  it  is  not  displaced  by  the  weights. 

It  is  a  matter  of  feeling  on  the  part  of  the  mothers,  Avho 
have  to  watch  for  the  amount  the  child  Avill  tolerate. 


Counter-  extension 

b)  Counter-extension.  —  The  most  simple  method  of  effect- 
ing this  is  to  raise  the  feet  of  the  bed,  and  fix  the  patient, 
that  is,  restrain  the  child's  trunk  on  the  bed  or  frame  by 
means  of  a  few  Velpeau  bandages  (v.    fig.    ^07,   4o8).      One 


CONTINUOUS    EXTENSION    :    COUNTLIl   EXTENSION 


^•'9 


mi'^ht  also  make  counlcr-oxlensioii  by  placing  a  skein  of  very 
soil  xYOol  in  the  groin  and  ada[)ling  ihc  Iwo  cxlrenniLies  of  lliis 
skein  lo  Iwo  rings  fixed  at  llic  upper  part  of  the  lilllc  bed,  in  such 
a  wav  as  lo  pull  from  above  on  ihc  corresponding  side  of  the 
pelvis  of  the  child.  If  llie  Hmb  is  in  abduction,  the  skein  is 
placed  in  the  groin  of  the  affected  side,      if  the  limb  is  in  adduc- 


Fig.  /109.  —   Uii    lai„    [,\\-[,i  In   lii|i  J  ji  111  disease. 

tion,  the  skein  Avill  be  placed  in  the  groin  of  the  sound  side. 

Steadying  the  trunk  Avith  a  closely  fitting  waistcoat  of  ticking, 
the  ends  of  Avliich  are  fixed  lo  ihe  frame,  also  ensures  counter- 
extension. 

After  a  Avhile,  a  very  short  time,  the  care  of  the  extension 
may  be  confided  to  the  mother  or  to  a  nurse ;  that  is  ^vhy  1 
suggest  this  system  in  preference  to  any  other,  because  the  prac- 
titioner himself  can  scarcely  exercise  superintendence  every 
moment.      By  folloAving  carefully  your  instructions  and  after  a 


420 


CONTINUOUS    EXTENSION    :     COUNTER-EXTENSION 


little  practice,  intelligent  mothers  Avill  learn  to  do  much  by  con- 
tinuous extension ;  but  this  therapeutic  method  demands  very 
great  care  and  a  certain  amount  of  skill.  If  you  have  no  one 
you  can  rely  on,  it  is  better  to  give  it  up. 


Fig.  /iio.  —  The  medium  plaster. 


In  hospitals  where  there  are  many  patients,  it  is  not  the 
most  practicable  system. 

Lastly,  one  must  not  expect  more  from  continuous  exten- 
sion that  it  can  yield.  There  are  some  cases  of  painful  hip 
disease  or  of  obstinate  deformities,  where  it  Avill  not  answer. 

The  pain  can  only  be  soothed  by  a  good  plaster,  and  the 
deformity  will  only  be  effaced  by  correction  made  under  chlor- 
oform and  this  correction  cannot  be  completely  maintained 
except  by  a  large,  well-made  plaster  apparatus. 


HIP    DISEASE    :     THE    TECUMQl  E    OF    THE    i'LASTER   APPARATUS    /|2I 


S.    THE  METHOD    OF   MAKING    A     PLASTER    FOR    HIP    DISEASE. 

There   arc  lliiec   |)all('iiis  of  plaster  apparatus  for   the  treat 
ment  of  hip   disease'.   Thev  diHer  only  in 
their  lower  part. 

The  large  plaster  reaches  from  the  false 
ribs  to  the  toes  (fig.  ^og). 

The  medium  plaster  slops  at  the  middle 
of  the  leg  (fig.   '|io). 

The  small  plaster  stops  at  the  Hnc  of 
the  knee-joint,  and  leaves  the  movements  of 
the  knee  at  liberty  (fig.  /iii).  (.,       ^' \    '^-^ 

The  Indications  for  the  Large,  the  Medium 
and  the  Small  Plasters^ 

The  first  is  indispensable  in  the  painful 
cases  of  hip  disease  or  those  having  a  ten- 
dency to  be  deformed;  more  simply  let  us 
say  that  it  is  applied  to  all  hip  diseases 
(without  distinction)  during  the  period  of 
development  of  the  disease. 

The  second  is  applied  to  cases  Avhich 
are  cured,  when  the  patient  is  first  allowed 
to  stand. 

The  third  is  used  six  months  later.  It  is  Avorn  for  a  year 
and  a  half  at  least,  until  all  apparatus  are  dispensed  Avith. 

For  town  children,  the  medium  and  the  small  plasters  are 
not  often  used.  Instead  of  them,  Avhen  the  child  begins  to 
walk,  he  Avears  a  large  celluloid,  rigid  al  the  hip  joint,  but 
jointed  at  the  knee  and  at  the  foot. 

\A  e  liaA^e  pointed  out  at  length,  in  our  first  chapter,  the 
technique  of  the  plaster  apparatus  and  Ave  refer  you  to  it  for  all 
the  generalities.  ^\e  Avill  mention  here  only  AAhat  specially 
refers  to  the  plaster  for  hip  disease. 


Fig-  in.  —  Tlie  small 
plaster  apparatus  for 
walking  (applied  when 
the  hip  disease  is  cured). 


I.  See  thesis  of  Dr.  L.  Saint-Beat,  iqo6. 


4i!2 


TREATiIE>"T    OF    IITP   DISEASE 


There  are  two  conditions  to  fulfil  in  order  to  make  a  good 
apparatus  for  hip  disease. 

The  Jirst  is,  not  to  interpose  betAveenthe  plaster  and  the  parts 
to  be  supported  a  layer  oi cotton  wool,  alloAving  the  bones,  when  the 
wool  has  become  uneven,  to  move  in  the  interior  of  the  apparatus. 

The  second  condition,  is  to  carefully  shape  the  upper  margin 


Fig.   413.   —  Calot  table  for  the  construction  of  plaster  apparatus  for  the  lower 


limb. 


of  the  pelvis,  to  mould  the  iUac  crests  by  pressing  into  the 
plaster  with  the  thumb,  above  the  crests.  Without  this,  they 
will  be  able  to  rise  and  fall  freely  and  deformity  will  be  repro- 
duced inside  the  plaster  and  in  spite  of  the  plaster. 

Here  are  a  few  simple  and  safe  rules  w  hich  must  be  followed 
in  order  to  make  a  good  plaster  for  hip  disease  at  the  first  attempt. 

a.  As  to  the  covering  of  the  5u6/ec/,  instead  of  cotton  avooI, 
cover  the  child  with  an  ordinary  jersey  —  or  even  tw^o  jerseys 
one   over   the  other  (slipped   on  like  pants)  :    the  sleeve  will 


THE    TECll.MQLE    OE    THE    I'LASIEK    AI'I'AKMT 


423 


cover  llie   Icfr.  and  llie  lower   borJer  nf  llic  jersey   \\ill  become 
tlie  iip[)er  bonier  (iig    4i3). 

I'or  the  large  apparatus,  wbicli  readies  from  the  false  ribs 
down  lo  tlie  loes,  as  tlie  sleeve  ends  al  the  middle  of  the  leg 
and  does  not  cover  the  foot,  you  will  make  a  sock  of  the  other 
sleeve  of  the  jersey  cut  beforehand.      T\\e  upper  brirder  of  such 


Fig.  /i  i3.  —  By  pushing  or  by  pulling  (with  the  control  of  the  dynamometer),  one  makes 
abduction  or  adduction,  rotation,  external  or  internal,   flexion  or   hvperestension. 

sock  will  overlap  the  loAver  extremity  of  the  other  sleeve  about 
as  far  as  the  knee. 

The  child  thus  clothed  in  jersey,  or  rather  double  jersey, 
in  placed  upon  a  pelvi-support  of  which  the  plane  of  support 
is  situated  at  i5  or  20  cm.  above  the  plane  of  the  table  —  a 
pelvi-support  Avhich  you  can  improvise  everywhere,  Avith  two 
boxes,  two  foot-stools  or  two  piles  of  books,  in  such  a  Avav  as 
to  support  on  the  one  part  the  shoulders  and  the  head,  and 
on  the  other  part  the  pelvis  of  the  patient  (v.  fig.  4 16). 


424 


T.REATi\IE>T    OF    HIP    DISEASE 


The  feet  are  held  in  the  desired  position  by  an  assistant 
Avho  pulls  on  the  sound  leg,  if  it  is  the  shorter,  or  pushes 
against  it  if  it  is  longer  than   the  affected  leg;  a  second  assis- 


Fig.  /ii_'|.  —  Our  table  for  hip  disease  -«Licb  may  l;e  used  in  the  treatment  of  other 
orthopoedic  aiTections  of  the  lower  limbs  (for  instance  the  congenital  luxation  of  the 
hip  joint).  The  pelvis  is  firmly  fixed  and  the  iliac  crests  are  modelled  by  two 
cup-shaped  pieces  or  metal  splints.  The  left  thigh  is  found  here  in  the  position 
we  have  given  for  the  treatment  of  luxation  of  the  hip  joint  in  coxitis  (v.  fig.  iOi) 
and  also  for  the  treatment  of  congenital  luxation  of  the  hip  joint;  the  left  thigh  is 
found  in  the  "  first  position  ",  that  of  the  first  plaster  in  the  treatment  of  luxation, 
while  the  right  thigh  is  found  in  the  "  second  position  ",  that  of  the  second  plaster 
(v.  pp.  7/16  and  701   . 


tant  presses  upon   the   knee   of  the  affected  leg  and  upon  the 
pelvis  in  order  to  keep  up  extension  or  hyper-extension. 

Keep  then,  in  your  practice,  to  the  employment  of  these 
improvised  pelvic  supports.  So  you  see  that  there  is  no  need 
to  buy  beforehand   these  pelvic  supports  or  those  tables  which 


THE    TtCllMOLE    Ol     Till:    PLASTEU    Al'PARATUS  /|25 


Fig.   /ii5.   —   The   child  clothed  in  his  simple   or  double  "    tijfhfs 
worn  after  the  manner  of  pants. 


Fig.  iiO.  —  Improvised  pelvic-support. 


426    PLASTER    IN    HIP    DISEASE.   JERSET,     BANDAGES    AND    ATTELLES 

are  invented  almost  everywhere  and  Avhich  are  only  "  objets  de 
luxe".  Vse  have  had  a  table  constructed  ourselves  and  we  give 
a  representation  of  it  here  (see  fig.  /ii2  to  4i4)  in  order  to 
show  you  precisely,  that  its  role  may  be  filled  as  perfectly, 
and  at  much  less  expense,  by  the  improvised  support  of 
Avhich  1  have  spoken  (v.  fig.    /iio  and  4 16),   with  the  help  of 


Fig.   !^I-.  —  Rolling  the  first  bandage. 

assistants,   also  improvised,   which   you  Avill   find  everywhere, 
in  the  very  surroundings  of  your  patient. 


b.     Construction  of  the  Plaster. 

You  prepare  your  plastered  strips  in  the  way  described 
for  the  apparatus  in  Pott's  disease,  that  is,  you  will  prefer  plas- 
tered strips  dusted  beforehand  to  strips  dipped  in  the  plaster 
cream  (see  Chap,  i  and  Chap.  v). 

You  apply  the  strips,  observing  the  recommendations 
already  given. 

You    must    spread  out  the  strips,   apply    them    exactly^ 


APPLY    THE    JtANDAGES    EXACTLY    AND    WITHOUT    PRESSURE       /jay 

bill  without  pressure.  If  you  spread  Ihcm  out,  there  A\ill 
be  no  ridyes  antl  no  huiilng.  If  llic\  arc  applied  exactly, 
the  apparatus  A\ill  m.t  be  too  loose.  If  they  are  applied  Avith- 
out  pressure,  the  apparatus  will  not  be  too  tight  (fig.  4 17). 

Circular  turns  are  made  over  the  trunk,  without  it  being 
necessary  to  make  reverses.  At  the  groin,  make  a  spica,  as 
you  would  wllh  a  linen  bandage.      At  the  ihidi.  at  the  le?  and 


Fig.   4 1 8.  —  The  last  strip. 


at  the  foot,  again  make  circular  turns  exactly  applied,  without 
reverses  (fig,   fiiS). 

There  must  be  three  strips  ^  5  metres  long  and  from  10  to 
12  cm.  wide,  for  a  plaster  for  a  child  of  ten  years. 

Remember  that  the  apparatus  breaks  especially  in  the 
inguinal  region.  Strengthen  it  at  that  point  by  folding  the  strip 
several  times  on  itself,  or  by  overlapping  several  spicas  one 
over  the  other  (fig.  419),  or  more  simply  Avith  a  plastered 
attelle  passed  "  en  cravate  "  around  the  hip  joint   (Fig.  420). 

I.  Ttiree  strips  suffice,  provided  that  attelles  are  added. 


428       HIP    DISEASE. 


TECHMQUE    OF    THE    PLASTER    APPARATUS 


The  Plastered  Strengthening  Attelles. 

The  apparatus    may  be  made  exclusively  of  strips,    but  I 
Avould  advise  you  to  make  it  rather  with  strips  and  attelles,  as 


Fig.  !iig.  —  To  consolidate  the  fragile  part  of  the  apparatus  at  the  level  of  the 
affected  groin,  one  folds  the  bandage  over  itself  several  times  which  takes  the 
place  of  the  strengthening  pads. 

you  did  in  the  plaster  for  Pott's  disease.  The  plaster  is  then 
stronger,  more  regular  and  more  easy  to  make. 

We  have  described  in  the  Generalities,  Chap,  i,  the  method 
of  preparing  attelles  and  plaster  cream. 

For  a  plaster  in  hip  disease,  we  introduce  four  attelles. 


Fig.    .'|2o.  —  Altelle  "  en  cravale  "  for  strengthening  the  groin 

a.  The  attelle  ••  en  cravate  "  already  pointed  out,  is  made 
with  three  thicknesses  of  tarlatan  12  cm.  wide  and  of  a  length 
sufficient  for  surrounding  the  hip  joint  (fig.  /iao). 

b.  A  circular  pelvic  attelle  to  strengthen  the  pelvic  and 
abdominal  portion  of  the  apparatus  (three  thicknesses  of  tar- 
latan :  length  equal  to  the  circumference  of  the  pelvis,  height 
equal  to  the  distance  from  false  ribs  to  the  line  of  the  trochan- 
ters, fig.  421). 

c.  and  d.  Two  attelles  intended  to  strengthen,  in  front 
and  behind,  the  leg  portion   of  the  apparatus.      They  have  a 


APPMCVTION    OF    THE    I'LASTEUCI)    I'ADS 


^29 


length  equal  lu  the  distance  from  ihe  ihac  spine  to  tho  loes  and 
a  breadth  equal  to  half  the  greatest  circumference  of  the  ihi^di. 


Fig.   /|2i.  —  The  circular  attelle  for  tlie  abdomen. 

\ou  may  replace  these  tAvo  attelles  by  a  single    attelle,  like  a 
splint  (fig.  421  bis).      The  respective  place  of  the  attelles  and  the 


Fig.    421  bis.  —  Strengthening  Attelles  : 

I.  As  a  waist-bell.  —  2.      "  en  cravale  "  at  tlie  root  of  the   thigh.  —  3.     As  a  splint 

beneath  the  limb ;  this  replaces  the  two  attelles,  anterior  and  posterior. 

strips  is  the  same  as  for  the  plaster  corset  (see  Chap,  v),  that  is, 
you   make  a   first  covering  Avith   the  plastered  strip,  then  you 


43o 


HIP    DISEASE. 


MODELLING    THE    PLASTER    APPARATUS 


place  in  position  the  four  attelles,  and  lastly  you  make,  over 
the  whole,  a  second  covering  with  strips. 

BetAveen  the  diflferent  layers  of  plaster,  to  strengthen  them, 
you  spread  Avith  the  hand  a  layer  of  i  to  2  mm.  of  paste  (true 
mortar)  which  binds  the  whole. 

e.  How  to   model   the   supported  parts    (iliac   crests,  knee). 


Fig.  /|22.  —  The  apparatus  liiiislieil,  llie  chiltl  is  replaced  on  the  table.  —  Carefully 
verify  and  rectify  the  position.  —  Model  the  iliac  crests.  —  Enclose  the  patella 
between  two  lateral  depressions. 


The  modelling  is  clone  when  the  child  has  heen  taken  down 
from  the  pelvi-support  and  replaced  on  the  table,  a  few  minutes 
before  the  plaster  sets  (figs.  422  to  429). 

The  iliac  crests  are  modelled  by  making  above  (not  upon  the 
orests  themselves,  but  above)  and  in  front  of  them,  a  depression 
in  the  plaster  with  the  hands  slightly  flexed,  the  thumb  in  front, 
the  other  fingers  above.  Press  doAvn  also  the  plaster  below 
the  iliac  crests,  in  such  a  w^ay  as  to  place  them  between  two 
depressions;  the  upper  one  the  deeper,  in  the  iliocostal  space, 
and  the  lower,  less  marked,  over  the  external  iliac  fossa. 

With  the  hands,  vou  lower  or  raise  one  of  the  sides  of  the 


MODELLINU     llll'     I'l.ASltU    HOLM)    THE    i'ELVlS    AND    Tlli;     KNEE     '|3 1 


pelvis,  according  lo  ihe  iritllcalioiis  wliicli  are  present,  -^pply 
llic  plaster  evenly  over  llie  condyles  ol"  llie  femur  and  on  each 
side  of  llie  |ial(lla,  enclosing  consequently  the  patella  between 
two  depressions. 

There  is  no  other  secret  iu  making  perfect  apparatus  for  hip 


Fig.  ^20.  Fig.  ',2',.  Fig.  425. 

Fig.  ^23.  —  A  Ijad  apparatus  :  —  apparatus    witiiout  any    depressions,    such    as  are 

unfortunately  too  often  made. 
Fig.  /|2'i.  —  In  this  apparatus  the  iliac  bones    can  be    freely  inclined  and  displaced 

A  badlv  made  apparatus. 
Fig.  42  5.  —  A  -well-made  apparatus,  well  modelled  over  the  iliac  crests  and  at  each 
side  of  the  patella.     The    iliac    bones   cannot    be   displaced   either    upwards    nor 
downwards.      The  knee  cannot  turn  in  the  apparatus. 

disease,   and    in  it   all.  you    see,   there  is    no   "  Avitchcraft  ". 

AA  ith  such  a  plaster,  a  leg  Avhich  is  in  a  good  position 
cannot  possibly  lose  that  position  (fig.  :i3o). 

As  to  vicious  positions,  when  once  rectified  and  maintained 
by  a  good  plaster,  the  correction  will  not  lose  even  —  I  do  not 
say  centimetres,  as  is  the  case  with  apparatus  made  by  certain 
careless  surgeons  —  but  millimetres. 

Trimming    the   Apparatus.  —  A   quarter  or   half  an   hour 


432       HIP    DISEASE. 


TECHNIQUE    OF    THE    PLASTER    APPARATUS 


after   the  plaster  is    "  set  ",  trim  and  make  the  edges  even  by 
cutting-  down  to  the  jersey  only.      Cut  first  the  upper  edge  of 


Fig.  426.  —  ^lelliod  of  moulding  the  iliac 
crests :  —  position  of  the  hands  for  mould- 
ins;  the  apparatus  upon  tlie  iliac  crests. 


Fig.  427.  —  Sketch  of  an  appa- 
ratus -well  modelled  above  the 
iliac  bones. 


the   plaster  over  the  abdomen,   in   the   form  of  a  crescent,   in 


Fig.     /i28.    —   Schematic    sketch   of   the 

knee  in  a  badly  made  apparatus ; 

the  apparatus  being  circular,  the  knee 
is  able  to  turn  round  in  everv  direction. 


g    li2<j.  —  An  apparatus  well 

made.  The  depressions  made  at 
d.,  on  each  side  of  the  patella, 
prevent  the    knee   turning   round. 


such  a  way  as  to  leave  the  umbilicus  exposed,  then  disengage 
the  genital  organs  and  the  toes  (v.  fig.  /jog).     After  which,  the 


nil'    DISEASE.     1ECI1M(JLE    Ul     THE    PEASllCll    AI'l'AUAlLS       l\'6'6 

cliild  may  becarriod  back  lo  his  bed;  bill  it  is  wise  not  to  move 

him  l(»o  much  until  the    next   ilay;   during    those   twenty  four 

hours,  the  plaster,  still  drier,  will  have  gained  much  in  resistance. 

Opcnim/s  in  lite  J^laslcr.  —  II  is  oidy  on  Ihe  next  day   ihal 


Fig.   /|3o.  —  The  plaster  in  its 
rousK  state. 


Fig.  /i3o  bis.   —  The  plaster  trimmed 
and  polished. 


you  Avill  make  any  opening  necessary  for  treating  an  abscess  or 
making  an  injection  into  (he  joint  (fig.  43i). 

If  the  child  complains  of  pain  at  some  point  — heel,  malleoli, 
iliac  spines  —  you  may  release  those  points  by  removing  a  small 
piece  of  plaster,  as  it  were  punched  out.  The  openings,  great 
or  small,  are  simply  made  with  a  good  knife;  cut  millimetre 
by  millimetre  until  you  feel  you  no  longer  cut  the  plaster  but 
touch  the  jersey ;  by  proceeding  cautiously  you  need  have  no 

Calot.  —  Indispensable  orthopedicf.  28 


434 


HIP    DLSEASE. 


THE    REDRESSMENT    OF    DEFORMITIES 


fear  of  touching  the   skin  and  you   Avill    noAv    appreciate   the 
advantage  of  the  douhle  jersev. 

h.  —  TECHNIQUE  OF  REDRESSMENT  OF  THE  HIP-JOINT 

Before  describing  this  technique,  we  must  remind  you  of  the 


Fig.  /i3i.  —  The  medium  plaster  with  openings  at  the  hip  and  at  the  knee. 

differences  which  exist  between  recent  deformities  (abduction)  and 
old  deformities  (adduction). 

Abduction  at  the  beginning  of  hip  disease  heing  due  to 
muscular  contraclions,  is  nearly  ahvays  easily  corrected. 

This  is  very  fortunate.  For  at  the  beginning,  especially 
in  the  painful  cases,  one  is  dealing  with  active  tuberculosis; 
and  our  duty  is  to  make  the  correction  by  the  most  gentle  and 
shortest  manoeuvres,  abstaining  above  all,  from  the  manoeuvres 
of  movement  in  all  directions  so  highly  praised  by  Bonnet  (of 


CORUECTIO.N     WllllUUr     llIK    IIELl'    Ol'    CllLOUOl'UHM 


435 


Lyons),  ^vllicll    are    uiifoiluaalcly    lliose    described    in   all    llie 
classical  Irealiscs. 

Violent  and  prolonged  inaua'uvres  are  dangerous  because 
[\\v\  may  load  lo  a  i)ruising  of  the  virulent  fungosilics  and 
c\.iilo  iiK^culaliita   at  a    distance.      One  will  carry  the   affected 


Fig.  432.  —  Vicious 
ankylosis,  flexion,  ad- 
duction and  inlernal 
rotalion. 


Fia;.  433.  —  Correction 
without  chloroform. 
First  apparatus  (i"sta- 


Fig.   'i34.  —  Second  ap- 
paratus {■2"'.  stage). 


limb  directly  and  as  gently  as  possible,  inwards  anddoAvnAvards. 

If  the  correction  demands,  so  as  to  be  complete,  some 
vigorous  movements,  one  will  be  satisfied,  for  the  time  being, 
with  a  partial  correction  to  be  completed  two  months  later. 

The  vicious  position  in  adduction  supervening  in  hip 
disease  of  old  standing,  calls  for  more  vigorous  tractions. 

These  manoeuvres  are  then  permissible,  as   the  lidicrculosis 


436         HIP    DISEASE.    REDRESSMEXT    WITHOUT    CHLOROFORM 


is  very  attenuated  and   sometimes  extinct  in  such  old  cases  of 
hip  disease. 

The  redressment  may  he  made  Avith  or  without  chloroform. 

r'.  Method  :  Correction  without  Chloroform. 

[By  stages  :  a  new  plaster  every  month,  fig.  /ISa  to  436). 

One  may  hring  ahout  a  correction  hy  making  a  new  plaster 


Fig.  /|35.  —  Third  apparatus        Fig.   430.  —  Sixtli  apparatus  (G"".  stage). 
(3"'.   stage).  The  correction  is  perfect. 

apparatus  every  month,  each  new  apparatus  placing  the  limb 
m  a  position  more  and  more  correct.  One  gains  several 
degrees^each  time,  without  pain,  by  slight  traction  and  slight 
pressure  -made  immediately  after  the  application  of  the  last 
plastered  strip  and  kept  up  until  the  plaster  is  quite  dry. 

One  obtains  in  this  way,  in  the  space  of  from  two  to  four 
.months,  surprising  and  often,  complete  corrections. 

Nevertheless,  for  very  marked  deformities,  one  is  generally 


REDRESSMEM'     (  NDEU    CIII.OKOFORM 


437 


obliged  to  make  a  last  sitting  lor  correction  under  chlorolorm, 
if  oncAvishes  to  do  aAvay  \\  ith  ihe  very  slight  deformity  wliicli 
persists. 

;j""'  Mi-TiioD  :  Correction  with  Chloroform. 

[See  .\n:isili('sia,  chap.  Ih. 

Correction  \\\[h  ana'stliesia  is  very  simple;  and  anlcss  it  is 


Fig.   .'iSy.  —   Rit;!it  hip  disease  with  extreme  aljduction. 

a  case  of  painless  hip  disease  and  oi  recent  and  slifjhtly  vicious  atti- 
tude. 1  advise  you  to  have  recourse  to  it. 

AMth  the  help  of  chloroform  one  can  accomplish,  in  a 
minute  or  tAvo,  Avithout  any  violence,  the  correction  of  recent 
deformities.  At  once,  one  applies  a  good  plaster  apparatus ; 
the  Avhole  thing  takes  from  six  to  ten  minutes  and  secures 
three  months  rest  and  perfect  comfort  for  the  child. 

It  is,  as  one  can  see,  the  most  easy  and  the  most  rapid  method. 

A\e  Avill  now  describe  in  order  :  —  i*",  the  redressment  of 
recent  deformity  (in  abduction) ;  2"'',  the  redressment  of  an 
older  deformity  (in  adduction);  3'^',  the  redressment  of  old 
ankylosis  of  the  hip  joint;  4^'%  the  treatment  of  luxations. 


438  HIP    DISEASE.     REDRESSMENT    OF    THE    DEFORMITIES 


1^'  Case  (fig.  487).  —  Hip  Disease  with  Abduction  and  Lengthening 

(Hip  disease  dating  severa'  weeks  or  montlis,  more  or  less  paiiiful). 

The  patient   is  removed  to  an  ordinary  table  which  is  quite 


Fig.  438.   —  Correction,      l"  sluje  :   Placing  in  position  the  pslvis  and  trunk 


firm,  and  then  put  to  sleep.  If  the  coxitis  is  very  painful,  the 
patient  should  be  put  to  sleep  previously  in  his  bed  and  then 
carried  to  the  table. 

i^'  STAGE  (fig.  438).  • —  Placing  in  position  the  pelvis  and 
trunk.  —  Place  the  trunk  and  pelvis  flat  and  in  good  position 
on  the  table.  This  is  easily  done  :  it  suffices  to  take  the  afTected 
leg  by  the  foot  and  the  knee  and  carry  it  in  the  direction  of  the 
deviation,  that  is,  further  in  abduction  and  in  flexion  until 
you  have  in  this  Avay  totally  obliterated  the  lumbar  hollow  and 
brought  back  the  iliac  spine  of  the  affected  side  to  the  same 
level  as  that  of  the  sound  side,  so  that  they  are  both  placed  in 
the  same  line  perpendicular  to  the  axis  of  the  body. 

You  have  thus  before  your  eyes,  in  it's  entirety,  distinctly 
seen,  the  vicious  attitude  to  be  corrected. 


CORRECTION    OF    ABDUCTION    (Willi    l.ENGTIIEMNG )  /,3fj 

Fix  the  Inink  and  |)el\is  in  the  nMnn;il  pi.silioii  \\Iiicli  vou 
have  given    ihciii. 

\ou  cause  the  alTected  lliigh  to  manoeuYrc  round  the  pelvis, 
in  order  to  bring  it  hack  to  a  correct  position. 

2'"'  STAGE  (fig.  '109).  —  Fixation  of  the  Pelvis  and  Trunk  in 
the  Normal  Position.  —  One  assistant  only  is  generally  suffi- 
cionl  to  cfTcct  this  lixalldn;  the  same  one  ^vho   lidd  the  sound 


Fig.  ASy.  —  Correction,  i 


i-!'/..  :    Tlie   marjner  of  fixing  the  pelvis  aad  trunk 
the  normal  position. 


limb,  ^vhilst  you  Avere  placing  the  pelvis  in  position  by  acting 
on  the  affected  leg.  This  assistant  bends  the  sound  limb  over 
the  abdomen,  and  by  the  intermediation  of  the  flexed  limb 
presses  on  the  trunk  and  on  the  pelvis  in  such  a  way  as  to 
keep  them  in  close  apposition  Avith  the  lal}le,  taking  care  that  the 
two  iliac  spines  are  always  at  the  same  level  and  that  the 
holloAA"  remains  obliterated. 

An  additional  assistant  will  render  this  fixation  still  more 
perfect;  kneeling  down  by  the  affected  side  of  the  patient, 
seizing  Avith   one  hand  the  ischium  of  the  aflFected   side,   Avith 


44o      HIP    JOI>T    DISEASE.    TECH>IQUE    OF    THE    REDRESSME.XT 

the  other  the  ala  of  the  ilium,  he  pushes  forward  the  ischium 
and  hrings  hack  the  iliac  crest  behind  upon  the  plane  of  the 
table,  in  such  a  manner  as  to  prevent  the  iliac  crest  of  the 
affected  side  tilting  forward,  ^vhich  it  ^vill  have  a  tendency  to 
do  when  you  carry  the  affected  femur  into  good  position. 

3"'  STAGE   (fig.  \'\o).  —  Correction. —  The  pelvis  placed  in 


Fig.  iio.  —  3".  stage.  Correction.  The  deformed  leg  is  being  carried  inwards 
and  dowmvards  by  the  left  hand  of  the  surgeon  -while  the  right  hand  pulls  slightly 
on  the  foot  to  facilitate  the  correction. 

position  and  well  fixed,  you  have  only  to  carry  the  femur  into 
the  normal  position  : 

With  one  hand  you  seize  the  knee,  with  the  other  the  foot. 
With  the  first  hand  you  pull  slightly  upon  the  femur,  as  if 
to  detach  it  from  the  iliac  bone;  then,  Avith  a  simple  pressure 
of  one  or  two  kilograms,  you  push  it  directly  into  the 
correct  position,  that  is  to  say,  inwards  and  downwards.  It 
is  sufficiently  inwards  when  the  knee  reaches  the  prolonged 
median  line  of  the  body,  and  it  is  sufficiently  downwards  when 
the  ham  of  the  affected  side  touches  the  table. 

Having  in  view  the  tendency  which  the  leg  Avill  have  later 


REDRESSMENT    OI-     A    RECENT    DEVIATION,     IN    ABDLGTION  ^Z,  I 

on  to  pass  into  adduclion.  allow  an  abdudioii  df  fiom  lo"  to 
lb"  to  persist.      On    the  other   hand,  one   onglil  lo   go    a   little 

urlliec  towards  deflection  and  malvc  a  slight  hyper-correction. 
To  do  this,  carry  the  pelvis  over  the  loAver  end  of  the  table  and 

ower  the  aflecled  knee  for  5  or  lo  cm,  below  the  prolonged 

plane  of  the  table,  pressing  on  the  knee  from  above  do^vn wards. 

This    manoeuvre    requires    a    few    seconds.      You  verif\    the 


Fig.   ^i^r.  —  Correction  iconlinued  .     The  sound  leg  being  placed  back  in  extension, 
the  surgeon,  holding  the  feet,  verifies  the  correction. 

correction  (fig.  44 1)  by  taking  the  two  feet  (the  sound  flexed 
leg  has  been  put  into  normal  extension)  and  comparing  the 
position  of  the  two  malleoh  and  the  two  heels,  Avhilst  an  assistant, 
one  hand  on  the  knee  of  the  affected  side,  keeps  it  in  the  posi- 
tion of  hyper-extension. 

There  is  nothing  more  to  be  done  but  to  preserve  the  cor- 
rection thus  obtained,  by  a  plaster  apparatus. 

4"".  STAGE.  —  Construction  of  the  Plaster  (see  above,  p.  42o). 

5*''.  STAGE.  —  Verification  of  the  Correction  a  little  before 
the  Setting  of  the  Plaster.    —  The   apparatus  being  finished, 


1x1x2       HIP     DISEASE.    THE    REDRESSMENT    OF    THE    DEVIATIONS 

one  removes  the  child  from  the  pelvi-support,  places  him 
gently  on  the  table,  the  legs  projecting  over  the  end  to  facili- 
tate the  hyper-extension.  The  correction  is  again  verified,  com- 
pleted if  need  be,  and  maintained  very  exactly  in  position  until 
the  plaster  becomes  dry. 

The  assistant  who  models  the  iliac  crests  oiiaht  to  see  that 


'-# 

" 

\utk 

i 

1 

L 

of 

1 

H| 

^ 

^ 

l>i 

-  -  -  -    -    riassrss 

^M 

m 

^H 

'%:■  i  .-...,,  :-y.'<i^r^^i^J<)Sg^^ 

» 

■ 

Fig.  /|/|2.  —  Hip  disease  willi  adduction  already  a  year  and  a  half  old. 


the  iliac  spines  are  at  the  same  level  and  that  every  trace  of  the 
lumbar  hollow  is  obliterated;  to  do  that,  he  presses  vigorously 
from  before  backwards  (or,  more  correcQy.  from  above 
downwards  in  the  recumbent  position  of  the  trunk). 

If  necessary,  an  additional  assistant  acts  on  the  ischium 
and  the  iliac  wing,  as  Ave  have  mentioned  above,  to  effect  this 
obliteration  of  the  hollow,  which  can  never  be  overdone.  One 
can  assist  it  indirectly  by  making  hyper-extension  of  the  thigh;  to 
do  that,  an  assistant  presses  on  the  affected  knee  from  above 
downwards. 

You  attend  yourself  either  to  the  pelvis  or  to  the  feet,  and 
control  every  moment  the  perfecting  of  the  correction.  You 
pull  or  push  on  one  foot  or  the  other,  asking,  if  necessary,  for 
the  help   of  the   assistant  Avho  has   his   hands  above   the  iliac 


REDUESSMENT    OF    THE    UEVIAIIONS 


/i43 


crests  and  ulio  is  able,  in  pusliino- one  or  other  of  the  crests,  lo 
lower  or  raise  one  of  the  sides  of  llio  pelvis'. 

Duralion  of  llie  Interference. 
Correction   properly  called  takes  (Voui  one  to  two  minnles; 
the  construction  oi'  llie  apparatus,  five  (o  Ion  minnles;  the  set- 


Fig,   lilii.  —  Correction.      1"  sl'nje  :  placing  in   position  the   pelvis  and  trunk  (ttie 
iliac  spines  are  marked  bv  two  dots  . 

ting  of  the  plaster  takes,  afterw^ards,  six  to  eight  minutes;  the 
entire  length  of  the  correction  is  therefore  about  fifteen  minutes. 

I  have  supposed  a  case  where  chloroform  has  overcome,  by 
itself  alone,  nearly  all  resistance.  If  the  deviation  in  abduction  is 
very  old,  if  it  has  already  produced  fibrous  adhesions,  a  weight  of 
from  one  to  two  kilograms  is  eviden  tly  not  sufficient  for  correction. 

If  the  resistance  of  the  deviation  is  greater  than  that  force, 

1.  If  the  assistant  wlio  grasps  the  iscliium  puslies  it  upAAards  whilst  the  sur- 
geon -who  holds  the  foot  pulls  on  the  leg,  you  manage  thus  to  fix:  the  hip  in  the 
plaster  apparatus,  with  a  certain  amount  of  separation  of  the  articular  surfaces. 


444 


HIP    DISEASE. 


REDRESS.MEM    OF    THE    DEFORMITIES 


if  that  force  does  not  give  an  absolutely  perfect  correction,  it 
■will  always  give  you  a  very  appreciable  correction,  thanks  to 
chloroform.  Do  not  go  further,  if  you  Avish  to  be  very  prudent. 
You   will  complete   the   partial  correction   six  or  eight  weeks 


Fig.  444.  2°''  stage  :  Fisation  of  the  pelvis  and  trunk  by  two  assistants,  the  sound 
limb  bent  over  the  abdomen.  Here,  the  operator  alone  seizes  the  leg  to  move  it 
into  the  correct  position. 

later.  It  will  still  be  easy  then,  and  especially  it  will  be  no 
longer  dangerous;  for  the  tuberculosis  will  have  lost  much  of  its 
virulence  by  the  sole  fact  of  the  perfect  immobilisation  of  the 
hip  in  a  plaster  apparatus  for  those  two  months. 

2""^  Case  (fig.  442  1.  —  Hip  Disease  with  Adduction  and  Shorte- 
ning^. (This  is  the  ordinary  deformity  of  hip  disease  of  rather  long  standing, 
a  year  or  more). 

The    correction    of    adduction    (of  shortening)   necessitates 

I.  See  tlie  thesis  ofDr.  L.  Saint-Beat,  1906. 


CORRECTION    Ol'     ADDlCIKiN     Willi     SIIOUTKMNG 


/./|5 


goMcrally  more  ("oicc  tliaii  llmL  uT  abcliiclion;  bul  lliiscorreclion 
Avill  be  harmless  il  il  is  cairied  out  in  iho  following-  rnannoi-  : 
I"'.  STAGE  (fig.  443).  —  PhiciiKj  ill  iiosilioii  the  jiclois  and  Iriinh. 
—  The  pelvis  and  Irunlv  arc  [)iaccd  Hal  on  ihc  table,  and  in  iheir 
nDPniai  posilidii.  This  is  done  as  il  was  for  the  preceding  vicious 
position,  wilh  ihis  (hlTercnce,  thai  instead  of  carrying  the  affected 
leg  into  llexion  and  abducliou.  one   is  obliged  to  carry  it   into 


Fio;.  Ixl^h.  —  3"'.  staoe  :  Tlie  correclion  is  finislied. 


flexion  and  adduction,  so  as  to  succeed  in  obliterating  the  lum- 
bar hollow,  and  to  bring  the  two  iliac  spines  to  the  same  level, 
towards  the  same  perpendicular  to  the  median  axis  of  the  body. 

2°''.  STAGE  (fig.  444)-  —  Fixation  of  the  pelvis  in  this  posi- 
tion by  one,  or  better,  two  assistants     (As  above,  p.  438). 

3"*.  STAGE  (fig.  445).  —  Correclion.  —  '\ou  grasp  the  thigh 
of  the  patient  above  the  knee,  Avitli  both  hands,  whilst  an 
assistant  seizes,  Avith  the  left  hand,  the  bottom  of  the  leg  in 
the  neighbourhood  of  the  malleoli  and,  with  the  right  hand, 
grasps  the  middle  of  the  foot;  both  of  you,  by  an  associated 
and  well-combined  effort,  pull  on  the  limb  so  as  to  detach  it 
from  the  iliac  bone;  you  pull  in  the  direction  of  the  deviation, 


m 


HIP    DISEASE.   REDRESSMEINT    OF    THE    DEFORMITIES 


that  is,  upwards  and  inwards.  Then,  when  you  feel  that  the 
leg  "■  holds  "  less  to  the  pelvis,  you  carry  it  at  once  (pulling 
all  the  time)  into  the  normal  position,  that  is,  outwards  and 
doAvnwards,  in  order  to  obliterate  the  adduction  and  flexion. 

Adduction  is   corrected  Avhen  the  internal  part  of  the  knee 
arrives    in  the    prolonged  median  axis  of  the  body.      Flexion 


Fig.  446.  —  The  right,  sound  leg,  is  placed  in  exlension  Jot  ihe  preparation  of  ihe 
plaster  apparatus,  and  pushed  upwards.  The  left,  alTected  leg,  is  pulled  firmly  and 
carried  further  in  abduction.     This  traction  is  made  bv  one  or  two  assistants. 

is  corrected  when  the  ham   touches   the   surface   of  the   table. 

But  here,  correction  is  not  quite  sufficient;  a  hyper-correc- 
tion must  be  made.  \^  e  shall  have  hyper-corrected  the  flexion 
Avhen  the  knee  is  lowered  lo  cm.  below  the  plane  of  the  table, 
the  limbs  held  outside  it.  We  shall  have  hyper-corrected 
adduction  Avhen  the  knee  is  found  to  be  at  [\o"  or  5o°  outside 
the  prolonged  median  axis  of  the  body.  We  must  obtain  these 
4o"  or  5o°  at  once  if  we  wish  to  preserve  i5°. 

A.n  abduction  of  from  i5°  to  20^,  if  it  persists,  and  if  the 
joint  is  ankylosed   in  this   posilion,    will  compensate  the  slight 


AM<.\LOSlS    IS    XCARLY    ALWAYS    INCOMl'LETE    ( FIBROUS)         ^f^-j 

real  shorlening-  uiiicli  exisls  ueaily  always  iii  llie  case  where 
the  appareiil  shorlening-  is  very  great. 

A  liinbankylosed  in  abduction  is,  as  a  matter  of  fact,  lunc- 
tioiially,  that  is,  practically,  a  little  longer  than  it  ought  to  be 
with  the  osseous  material  it  possesses.  Inversely,  a  leg  ankylo- 
sed  in  adduction  will  be  functionally  and  practically  shorter 
than  it's  real  (it's  material)  length  would  suggest. 

\ou  will  therefore  carry  the  limb  into  an  abduction  of 
more  than  45'\  It  will  be  kept  fixed  for  several  months  in  a 
plaster  apparatus.  AMien  adhesions  have  been  produced  in  this 
position,  you  allow-  the  limb  to  return  a  little  iuAvards  with  each 
new  apparatus.  It  is  then  easy  enough  to  preserve  permanently 
the  15"  which  are  needed  to  compensate  the  real  shortening'. 

4"'  STAGE.  —  Vcrijication  of  the  position  and  plaster.  — 
Modelling,  as  above  (see  fig.  44  i,  page  44 1)- 

3"'.  Case  :  Ankyloses  of  the  Hip  Joint 

[in  cured,  or  apparently  cured,  hip  disease). 

After  the  study  of  the  second  case  comes  naturally  that  of 
the  correction  of  very  old  deformities,  of  the  correction  of 
vicious  ankyloses  luhich  are  only  a  more  advanced  stage  of  the 
deviation  in  adduction  of  Avhich  we  have  just  spoken. 

In  reality,  it  is  nearly  always  a  question  (v.  p.  4o6)  of  incom- 
plete, non-osseous  ankylosis ;  if  one  does  not  perceive  any 
mobility  of  the  femur,  this  does  not  imply  that  the  union  is  osseous 
and  complete.  It  is  necessary  for  you  to  have  tried  to  find  move- 
ments under  chloroform  before  you  can  affirm  that  there  are  none. 

If  the  ankylosis  is  incomplete,  one  effects  redressment ; 
if  it  is  osseous,  one  performs  osteotomy. 

A.    -  CORRECTION    BY   SIMPLE  REDRESSMENT. 
One  can  perform  this  redressment^  in  two  ways  :    either 

1.  Definite  persistent  abduction  ought  not  lo  exceed  i5  to  20  degrees, 
because,  above  that  amount  it  will  bring  about,  in  walking,  a  lo\vering  of  the 
pelvis,  prejudicial  to  the  regularity  and  elegance  of  the  gait. 

2.  See,  with  reference  to  redressment  of  ankyloses  of  the  hip, 

the  excellent  thesis,  full  of  information,  of  Dr.  Qucttier,   of  Berck  (189^). 


448       HIP  DISEASE.    THE    SIMPLE    REDRESSMENT   OF   ANKYLOSES 

without  chloroform,  in  several  sittings,  at  the  rate  of  one 
every  twenty  days,  by  partial  corrections  and  successive  plas- 
ters. After  3  or  5  plasters  and  two  or  three  months,  the  cor- 
rection is  obtained  (v.  fig.  432  to  436). 

Or  with  chloroform,  in  one  or  two  sittings. 

The  second  procedure  is  easier,  more  certain  and  less  pain- 
ful to  the  patient,  in  spite  of  contrary  appearances. 

You  know  already  the  direction  to  give  the  manoeuvres  of 
redressment,  but  one  understands  that  one  ought  here  to  use 
manoeuvres  much  more  vigorous  than  in  the  deviations  in  the 
same  direction  occurring  in  the  course  of  hip  disease,  and  of 
only  a  few   months  standing. 

You  will  redress  in  the  manner  described  above  for  the 
second  variety,  since  the  thigh  is  nearly  always  in  adduction. 
Proceed  gradually,  slowly,  patiently ;  correct  especially  by 
firm  traction  on  the  leg,  Avithout,  however,  neglecting  the 
pressure  on  the  knee,  or  rather  on  the  middle  of  the  femur. 

You  will  break  nothing  if  you  correct  degree  by  degree, 
methodically,  without  shocks. 

You  must  be  three  or  four  in  number  to  do  this.  Whilst 
two  assistants  pvdl  on  the  leg  and  the  foot,  two  others  should 
make  pressure  on  the  thigh  and  push  it  dowuAvards  and  out- 
wards; make  pressure  with  four  hands  evenly  and  methodi- 
cally, without  discontinuing,  for  lo,  12,  i5  minutes.  You 
will  then  arrive  at  the  result  aimed  at  —  Avithout  danger  —  if 
you  liaA^e  taken  care  to  press  rather  on  the  middle  third  of  the 
thigh  than  on  the  knee  exclusively,  because  exclusive  pressure 
on  the  knee  with  the  force  of  such  a  lever  would  expose  you  to  a 
fracture.  Or,  still  better  —  in  order  most  certainly  to  avoid  this 
risk  —  you  Avould  take  the  precaution  of  placing  four  Avooden 
splints  along  the  leg  from  the  trochanter  to  the  malleoli,  the 
splints  being  firmly  held  Avith  straps;  and  it  is  on  the  middle 
of  the  thigh,  thus  strengthened,  that  you  Avill  exert  pressure. 

It  will  often  be  necessary  for  you  to  spend  10  to  i5  mi- 
nutes, or  even  more,  in  continuous  traction  and  pressure  before 


HI  I'l  I  riE  ov  THE  ADDicrons 


/./. 


I '1 9 


oblaiiiiiiy  llic  iccjuired  ri'siill'.  lli.il  is  hd'oie  liaviii"-  carried 
the  anbcted  knee  lo  i5°  bclo\\  I  lie  plane  o\'  I  he  (able  and  /|0"  lo 
50°  outside  (he  median  axis  of  the  body. 

By  the  manoeuvres  of  rcdressmcnt  described  one  ads  al  ibc 
same  time  over  all  ibc  rcsislanccs.  Avliicb  arc  of  two  orders  : 

I**.  The  ex/ra  arliciilar  rcsislance  proceeding;-  from  llie  con- 


Fig.  447.  —  Rupture  of  the  adductors.  One  assistant  fixes  the  pehis,  the  othermoves- 
the  limb  into  hyper-extension  and  abduction.  The  operator  presses  his  thumbs  with 
all  his  strength,  over  the  point  of  the  upper  insertion  of  adductors. 


traction  of  all  the  soft  tissues,  but  especially  of  the  adductor  and 
flexor  tendons; 

2°''.  The  arliciilar  resistance  arising  from  contraction  of 
the  capsule  or  from  old  fibrous  or  osteo-fibrous.  adhesions  uni- 
ting the  tAvo  osseous  extremities. 

Instead  of  acting  at  the  same  time  against  the  diverse 
resistances,  it  is  often  preferable  to  isolate  them  and  attack 
them  one  after  the  other.  If  llien.  in  commencing'  the 
redressment,    you   are    hindered   by    the  cords   of  the    tendons 

I.  And,  in  certain  cases,  you  Mill  not  reach  it  at  the  first  attempt.  You 
Avill  have  only  half  a  correction  —  Aihich  yoii  Avould  complete  at  a  second 
siltinii'  for  rcdressmcnt,  made  three  or  four  weeks  later. 


Calot.  —   Indispensable  orthopedic? 


29 


45o 


HIP    DISEASE.    REDRESSOG    INCOMPLETE    ANKYLOSES 


which  appear  very  tense  and  hard,  you  must,  in  the  first  stage, 
look  to  them  specially  and  exclusively  and  thus  Avill  more 
easily  overcome  this  resistance.  This  obstacle  overcome,  the 
redressment  vs^ill  proceed  easily,  because  the  contracted  tendons 
represent  often  half,  or  even  more,  of  the  total  resistance. 


Fig.  /,48.  _  Fig.  Wg. 

Fig.  4/18.  —  In  adduction,  the  vessels  are  in  nearer  jiroxiniity  to  the  adductors  than 
in  abduction  (consequently,  move  the  thigh  outwards  as  far  as  possible  by  mode- 
rate movements,  before  making  a  tenotomy  on  the  adductors). 

Fig.  /|/|C).  —  Relations  of  the  tendons  and  vessels  in   the  position  of  abduction. 

There  are  two  ways  of  acting  on  the  tendons  :  one  surgi- 
cal, the  other  non-surgical. 

If  you  are  not  a  surgeon  keep  always  to  the  latter  and  you 
will  succeed  simply  by  the  pressure  of  the  thumbs  over  the  pro- 
jecting cord  of  the  contracted  tendons,  in  making  them  supple, 
by  kneading  them,  elongating  them  and  even  rupturing  them. 

a.  Rendering  supple,  kneading  and  stretching  of  the 
tendons.     You    will   carry   out    the   manoeuvres    indicated  in 


TENOTOMY    OK     Till:    l-LEXOlt     TI;M)0NS 


45 1 


Chap.  \iv  (/ /;/'o/>o.s'or  coiifionllal  (lislocati()ii(il'  (lie  lii|),  bulyou 
Avill  ranv   llirni  oiil   willi    llic    lliigh  cxIcirIccI.  and    iiol  ilexccl. 

Ii.    Rupture  of  the  adductor  tendons  (l\'^.  l\\-). 

Two  ihumbs  pressing  crosswise  over  iho  tendinous  cord 
which  one  or  Iwo  assistants,  pulling  llic  leg  outwards,  stretcli 
to  the  utmost.  Alter  a  pressure  of  i  or  a  minutes,  one  feels 
under  the  ihumbs  a  first  tendon  give  way,  then  a  second,  then 
the  others,  Avhile  the  limb  is  carried  oulAvards. 


Fin.  ',00.  —  Tenotomy  of  the  tlexors.  —  An  assistant  pulls  on  the  foot  -with  one  hand 
and  with  the  other  presses  on  the  knee  downwards  to  throw  the  ilexor  tendons 
into  prominence.  The  tenotome  is  entered  on  the  inner  border  of  the  sarlorius, 
I  1/2  cm.  below  the  iliac  spine.  The  operator  pushes  the  tendons  towards  the 
knife  with  the  fingers  of  the  hand  remainino-  at  libertv. 


The  rupture  of  the  flexor  tendons  with  the  thumbs  is  very 
difficult  and  causes  a  considerable  traumatism  ;  but  you  W'ill  suc- 
ceed ill  stretching  them  sufficiently  by  a  long  and  patient  kneading. 

c.   Tenotomy. 

If  you  are  a  surgeon,  you  will  prefer  tenotomy  to  rupture 
of  the  tendons  by  pressure  of  the  thumbs.  The  division  is 
more  expeditious  and  does  not  require  any  force. 

Sub-cutaneous  tenotomy  is  done  (fig.  448  and  449)  ^^J  ^^ 
incision  of  a  few  millimetres,  wTiich  prevents  most  surely 
all  chance  of  infection  and  is  also  simpler,  Avhatever  may 
have  been  said  to  the  contrary,  than  making  the  section  of  the 
tendons    by   the   open   method.   —  If  some   fibres   escape    the 


452 


HIP    DISEASE. 


CORRECTION    OF    FIBROUS    A?fKYLOSES 


tenotome,  they  are  easily  ruptured  by  making  traction,  after 
the  tenotome  has  been  withdrawn.  This  supplementary  trac- 
tion is  likewise  necessary,  though  in  a  less  degree,  in  open 
tenotomy,  as  the  contraction  Avhich  affects  all  the  tissues  of  the 
region  can  only  be  overcome  by  this   supplementary  traction. 

The  operation  is  performed  as  follows  : 

Instruments.  —  i",  a  pointed  tenotome;  2'"^  a  blunt 
tenotome,  or  even  an  ordinary  narrow  bistoury   may  be  used. 


Fig.  45 1.  —  Another  method  of  tenotomy  of  the  flexors.  Here  the  tenotome  is  intro- 
duced outside  the  tendons  ;  the  left  hand  of  the  operator  isolates  the  vessels  expo- 
sing the  flexor  tendons  to  the  edge  of  the  instrument. 


a.  Division  of  the  flexor  tendons  near  the  iliac  spine 
(sartorius,  tensor  fasciae,  sometimes  the  rectus). 

The  division  is  made  at  a  centimetre  and  a  half  beloAv  the 
anterior  superior  iliac  spine,  penetrating  inside  the  tendinous 
cord  and  cutting  in  an  outward  direction. 

Position  of  the  assistants  (fig.  /i5o).  —  A  first  assistant 
holds  the  sound  limb  firmly  flexed  over  the  abdomen,  to 
immobilise  the  pehds.  A  second  assistant  pulls  on  the  affected 
knee  and  carries  it  dowiiAvards  in  extension. 

i".  STAGE.  —  Cutaneous  incision.  —  One  makes  an  incision 
4  or  5  cm.  long  with  the  pointed  tenotome,  along  the  internal 
border  of  the  prominent   tendons,  one  and    a  half  centimetre 


TENOTOME     Ol-     THE     VDDUCTOHS 


A53 


beloAv  Iho  iliac  spine,  and  one  introduces  llie  poiiil  to  a  dcplli 
of  ahiiiil  Iwo  and  a  hall"  cenlimelres. 

a'"'.  STAGE.  —  One  lunis  llic  leiiolome  so  thai  ihr  culling 
edge  is  ouUvartIs;  or,  one  inlroduccs  iheblunl  tenotome  parallel 
to  the  incision,  to  the  same  dcplli,  then  one  turns  it  outwards. 

3'"''.  STAGE.  —  One  cuts  Avith  a  sawing  movement,  whilst 


Fig.  ^52.  —  An  assistant  chaws  the  leg  outwards  to  make  the  cord  of  the  adductors 
prominent.  One  cuts  the  tendons  from  without  inwards.  The  left  hand  is  occu- 
pied at  first  in  pushing  the  tendons  towards  the  tenotome,  then  in  raising  the  skin 
to  protect  it  from  the  movements  of  the  knife. 


the  left  index  fmger  brings  up  the  tendon  inwards  on  to  the 
edge  of  the  tenotome.  One  avoids  perforating  the  skin  on  the 
outer  side  with  the  point  of  the  tenotome. 

4"'.  STAGE.  —  A  jerk  and  a  cutaneous  depression  folIoAv  the 
section  of  the  tendons.  The  tenotome  is  Avithdrawn;  through 
the  skin  you  press  very  firmly  on  the  vessels  to  ensure  hae- 
mostasis. 

By  your  pressure  and  by  some  traction  by  the  assistant  at 
the  knee  the  division  of  the  tendons  and  the  correction  of  the 
flexion  are  accomplished. 


454       HIP    DISEASE. 


REDRESSMEM    OF    FIBROUS    ANKYLOSES 


b.  Tenotomy  of  the  Adductors  (fig.  452  and  453). 

The  operation  is  based  upon 
the  same  principles  as  the  prece- 
ding one,  with  the  few  shght  modi- 
fications which  one  anticipates; 
the  tenotome  penetrates  outside 
of  the  tendons  and  not  on  the 
inner  side,  the  assistants  drawing 
the  hmh  outwards  and  not  down- 
wards. The  division  is  made  one 
centimetre  below  the  upper  inser- 
tions along  the  external  border  of 


Fig.  .')53.  —  Tenotomy  of  the  adductors. 
The  tenotome  is  conducted  by  the  left 
index  finger,  the  pulp  of  which  pushes 
the  vessels  to  the  outside. 


Fig.  l\b'A.  —  Haemostasis  after  tenotomy  :  one 
expels  the  blood  by  pressing  firmly  the  frno  lips 
of  skin,  after  -which,  one  makes  compression. 


Fig.  Z|55.  —  Haemostasis.  An 
assistant  compresses  firmly 
"with  his  t"wo  hands,  furni- 
shed with  tampons, the  two 
small  wounds  produced 
by    the  double  tenotomy. 


the  cord  made  prominent  by  traction  outwards.      The  operator 
stands  at  the  outer  side  of  the  affected  Jimb. 


TUKATME.NT    OF    OSSEOUS    ANKYLOSIS    (vi-KY    U.VUIi) 


',J5 


Tliclefl  liiJo\  finger  is  placed  on  llic  pmminenl  cord,  wliicli 
is  llien  allowed  lo  ,i-lide  inwards  —  wilhont  lenioving  the  inde\ 
Cm^vi  wliicli  Ihen  lunches  (lie  onler  border  of  the  tendon. 
^^P"ii  III''  nail  iA'  [\\r  index  finger  one  places  the  back  of  the 
lenotonic,  which  is  then  pushed  into  the  tissues  to  the  deplh 
desired,  and  one  incises  the 
tendons  from  without  in- 
wards, avoiding  puncture  of 
the  skin  on  the  inner  side 
with  the  instrunienl.  One 
afterwards  sees  carefully  to 
the  arrest  of  any  bleeding, 
and  also  lo  abduction  in 
order  to  arrive  at  the  hyper- 
correction(  abduction  of  from 
35"  to  ^o"  at  least). 

Correction  in  the  two 
cases  is  kept  up  by  a  very  firm 
and  Avell  modelled  plaster 
apparatus.  The  compres- 
sion made  to  produce  has- 
mostasis  should  be  prolon- 
ged with  the  greatest  care 
This 


ere  osteotomy  may  be  perfor- 
med. —  I  Cervical,  or  rather  cer\-ico- 
trochanteric,   osteotomy  (tiie    most  useful). 

2.  Trochanteric       (also       recommended). 

3.  Sub-trochanteric  (generally    done,    but 
^^rong). 


until  the  plaster  sets 

compression  is  necessary  in 

order  to  avoid  sub  cutaneous 

htematomata  Avhich  might  become  infected  in  course  of  time. 


B.  —THE  CORRECTION  OF  ANKYLOSES  BY  OSTEOTOMY 

I  have  said  (p.  4o6),  that  you  will  scarcely  ever  have  to 
make  a  section  of  the  bone,  because  real  hip  disease  is  hardly 
ever  followed  by  osseous  ankylosis.  I  myself  do  not  make 
more  than  one  or  two  osteotomies  a  year  although  I  always 
have  several  hundreds  of  cases  of  hip  disease  under  treatment. 

Osteotomy  will  be  sub-cutaneous  for  the  same  reason  that 


456 


IIIP    DISEASE. 


OSSEOUS    A^^RYLOSES. 


OSTEOTOMY 


tenotomy  is,  because  sub-cutaneous  interferences 
are  less  harmful  and  offer  less  risk  of  infection  than 
those  which  are  done  by  the  open  method.  The 
osteotomy  severs  two  thirds  or  three  fourths  of  the 
thickness  of  the  bone,  and  one  finishes  the  section 


Fig.  /.Bg. 
dinary 
tome. 


big.  457.  Fig.   /i58 

Fig.  457.  —  Cervico-trochanteric  osteotomy.      Bad  transverse  direc- 
tion of  the  osteotome,  ^Yhich  would  penetrate  into  the  pelvis. 
Fia;.  458.  —  Good  direction;  —  should  be  nearly  vertical  in  some 


by  an  osteoclasis,  which  renders  the  interference 
quite  harmless. 

Where  should  the  bone  be  DivroED? 

From  the  orthopoedic  point  of  view,  it  ought  to 
be  done  at  the  level  of  the  angle  of  the  bend  (fig.  456). 

But  because  of  the  situation  of  the  old  morbid 
focus  which  may  not,  strictly  speaking,  be  entirely 
defunct,  it  is  better  that  the  rupture  should  be 
made  a  little  outside  that  point. 


llillMMll       M|-     v|    I'll  \-i  |;(;,;||  \  \  II   |;|i       (iv|!i)|ii\n  \.)~ 


Fifif.  ItGo.  —  Osteotomy.  —  T'  sla.jc.  —  Position  of  (lie  jiaHent.  In  lliis  figure  /|0o 
llie  handle  of  the  osteolome  is  held  too  higli.  It's  direction  must  follow  fas  in 
fig.  /1C2)  the  axis  of  the  diaphvsis. 


./„. 


Fig.  /|Gi.  —  Osteotomy.  —  /"  stage.  — 
Tl)e  osteotome  is  introduced  into  the 
cutaneous  incision  down  to  the  bone 
at  the  junction  of  the  trochanter  and 
the  neck.  Then  the  osteotome  is  tur- 
ned go  degrees  Fig.  /|(Jo.  See  also 
Fig.  1 1 15  and  n  iG). 


9.^     -,■; 


I 


g.  A62.  —  Osteotomy.  - —  5"'  sla'ye.  — 
The  direction  of  the  osteotome  is  then 
changed  :  it  should  correspond  to  a 
bisection  of  the  angle  formed  by  the 
femoral  diaphysis  and  Ihe  bicotylidian 
axis. 


^58 


HIP    DISEASE. 


OSSEOUS     A^'K1L0SES.    OSTEOTOMY 


It  will  therefore  not  be  made  close  to  the  iliac  hone  —  you 
would  be  too  near  the  old  focus  —  hut  at  the  most  external  part 

of  the  neck.  In  any  case  do  not  go 
below  the  middle  of  the  great  trochan- 
ter (fig-.  456, 1  or  2)  because  you  AYOuld 
then  be  too  far  from  the  angle  of  the 
bend  and  die  gain  by  your  operation 
would  be  much  lessened  from  the  point 
of  vicAY  of  lengthening  of  the  limb;  it 
is  for  that  reason  we  condemn  subtro- 
chanteric osteotomy  AA-hich  is  recom- 
mended in  some  AYorks ;  it  is  somewhat 
easier,  it  is  true,  but  it  is  distinctly 
less  adYantageous.  In  order  to  meet 
the  case,  you  may  approach  the  bone 
at  one  or  one  and  a  half  centimetre 
below  the  superior  border  of  the 
great  trochanter  (fig.  456,  i  and  a). 
The  section  should  not  be  trans- 
one  would  run  the  risk  of  pene- 


463. 


Yerse 

trating  the  ihac  bone  —  it  should  so- 


Carry  the  instru- 
ment quite  near  the  trochanter, 
further  outside  than  is  shewn 
in  this  figure.  The  osteotome 
is  driven  hy  a  few  strokes  of 
the  mallet,  making  a  section  of 

two-thirds  or  three  quarters  of      j^gfin^es  be  almOSt  YCrtical  (fig.    458). 
the  bone.  ^    "^        _       ' 

—  It  will  have  practically  the  direc- 
tion of  a  bisection'  of  the  angle  formed  by  the  diaphysisof  the 
femur  and  the  axis  of  the  acetabulum  (fig.  458  to  463). 

Then,  by  prolonged  pressure,  ensure  hfemostasis,  and  fix 
the  limb  in  hyper-correction  (fig.  465).  The  after-treatment  is 
the  same  as  for  simple  redressment.  One  leaves  on  the  large 
plaster  for  six  months,  then  one  makes  the  child  get  up  with  a 
small  apparatus  —  which  ayIII  not  be  dispensed  with  for  a  year 
and  a  half  later,  when  the  position  will  be  permanently  preserved. 


I.  This  indication  issufficient  for  practice,  because  one  has  never  todowith 
adductions  of  less  than  45  degrees  (in  osseous  ankylosis) .  But  the  indication  would 
no  longer  be  reliable  for  an  extrenme  adduction,  say  of  8o  degrees,  for  instance ; 
it  would  be  necessary  in  that  case  to'perform  subtrochanteric  osteotonay. 


TF.CIINKMK     Ol       >l   I'll  \- I  IKKillAN  I  r.UIC     ( Is  I  i:(  )  I  ( )\I  V  V"'<> 


Fig.  464-  —  Osteotomy  (continued).  The  section  ol'  the  hone  heing  made  lor  two- 
thirds  or  three-quarters,  one  removes  Ihe  osteotome  and  finishes  with  an 
osteoclasis.  To  do  this,  the  thigh  is  carried  very  firmly  into  flexion  and  adduc- 
tion as  if  one  wished  to  exaggerate  the  existing  deformity  (this  is  the 

first  stage  of  the  final  osteoclasis. 


Fig.   'i(J5-  —   Afterwards  (2°'  stage^   the  thigh   is  carried  into  the  corrected  position, 
that  is,  into  hyper-extension  and  forced  abduction. 


46o 


HIP    JOI>'T    DISEASE. 


OSTEOCLASIS 


Osteoclasis. 


Although  it  is,  in  reality,  a  little  more  traumatising  and  a  little 
less  precise  than  osteotomy,  manual  osteoclasis  may  he  of  service 
for  children  aa  hose  parents  do  not  wish  at  any  price  to  hear  one 


or    even 


Fio-.   Z|66.    —    Osteoclasis.   —    An    assistant   holds   the   pelvis  (or   better, 

3  assistants  firmly  fii  the  pelvis).  The  opei-ator  seizes  the  limb  (previously  straigh- 
tened bv  means  of  splints  tightly  strapped)  :  another  assistant  seizes  the  thigh  as 
near  as  possible  to  the  root,  and  both  of  them,  the  operator  and  the  last  assistant, 
push  the  thigh  downwards  and    outwards  until  the  bone  is  broken. 


speak  of  osteotomy,  nor  of  blood,  norof  a  hole  in  the  skin.  I  have 
performed  it  under  these  conditions  Avithout  accident,  Avith  an 
excellent  final  result.  ^cAcrtheless,  I  do  not  advise  you  to  have 
recourse  to  it  except  in  case  AA'here  the  X  rays  haA'e  demonstrated 
a  neck  A'ery  much  weakened  and  atrophied  —  or  Avhen  you  haA^e 
found,  under  chloroform,  a  feAA"  obscure  movements,  but  not 
marked  enough  to  justify  an  ordinary  redressment. 


TECIIMQL'E    or    OSTI.OCr.ASIS    IH-     Till;    IIIP    .IDINT  /|<i» 


In   llicse  two  cases.    \(iii    have  cvci-y  cliaiice  oi'  hi-caking  ihe 
bone  al  \\\c  iiccL  or  vcr\    near  llic  aii^le. 

In  oriler  lo  he   siiccessliil.   mmi   will    vhenLillicn    (lie    leuioral 


Fig.  .'1O7.  — Right  luxation,      r'lio^ilion  after  Fig.  468.  — 2°"'  stage.      The   left 
the  reduction    see   p.   4G2).      To  be  ([uile  leg  (sound)  is  still  in  a  plaster 

sure  of  iirimol)ilisation,  the    sound   tliii;ii   has  collar, 

hcjn  [>lasloroil  as  well. 


Fig.    iOg.—  'i'"  stage   (large  plaster;.  Fig.   '170. —  V"  >laue.  The  child  can  «alk. 


462 


HIP    30mT    DISEASE. 


OSTEOCLASIS 


Fig.  /iyi.  —  Luxation  of  right  liip 
joint.  Radiogram  on  Sept. 
2°%  1901. 


r"^5~^e 


Fig.  /172.  —  Sept.  23'''',  1 901.  One 
tries  to  reduce  by  an  abduction  of 
nearly  90  degrees,  but  without  suc- 
cess. 


Fig,  /173.  —  Sept.  20"',  1901.  In 
order  to  induce  the  femur  to  enter 
the  acetabulum,  it  was  necessary  to 
place  the  thigh  in  flexion  at  an 

acute  angle  on  the  abdomen,  and 
in  abduction  of  about  sixty  degrees. 


Fig.  /,75.  —  Oct.  28'\  1901.  Seeing 
this,  one  immediately  replaces  it  in 
the  old  position  of  abduction  and 
flexion;  the  radiogram  shcAvs  that, 
once  more,  reduction  is  accom- 
plished. 


;.  fql,.  _  Oct.  28'*,  1901.  A 
month  later,  one  attempts  to  les- 
sen the  flexion  and  abduction 
The  radiogram  allows  one  to  see 
that  the  femur  has  a  tendency  to 
escape  from  its  cavity. 


Fig.  /17G.  ■ —  Dec.  2  3"',  1 90 1.  New 
attempt  to  put  the  femur  in  abduc- 
tion of  go  degrees.  This  time  the 
leduction  is  maintained.  One  sees 
that  a  small  bridge  of  bone  has 
been  produced  between  the  edge 
of  the  cavity  and  the  femur. 


TUl-MMKNT    OF    ABSCESS    IN     HIP    DI^KV'-I.  V).'i 


Fi;;'.  .'177.  —  May  (J"',  iqo;!.  Tlie  I'l'imir  I' ig.  '178.  —June  22"',  1902  Abdiiclion  of 
has  been  replaced  in  posilion,  lillle  by  about  20 degrees.  The reduclion  is  main- 
little,  in  several  stages.  Tlie  re.luc-  lained.  The  small  bridge  of  bone  has  a 
lion  is  permanently  mainl.iined.  tendency  to  grow.  Tliccliild  walks  easily. 

diapliysis  by  means  of  four  Avooden  splints  held  by  straps 
tiglilly  fixed;  a  veritable  apparatus  of  Scullet  (v.  fig.  ''166). 

I'''.   STAGE  \  —  One  puts  tlie  Avooden  splints  in  position. 

2"''.  STAGE,  —  AA  bile  tAvo  or  three  assistants  hold  the  pel- 
vis, pressure  is  made  on  the  middle  of  the  thigh,  until  the 
bone  is  broken. 

4''\  Case.  —  The  Treatment  of  Luxations  of  the  Femur. 

I  said,  on  p.  '108,  that  if  the  head  of  the  femur  is  in  good 
condition,  which  is  very  rare,  one  makes  the  reduction  as  in  a 
congenital  luxation  of  the  hip  (v.  Chap.  xn). 

But  if  the  head  of  the  femur  is  destroyed  (lohich  is  the 
usual  condition),  one  may  then  place  the  trochanter  in  the 
bottom  of  the  acetabulum.  —  One  must  be  guided  here,  at 
every  step,  by  the  indications  afforded  by  radiography.  —  The 
treatment  is  difficult  and  it  is  reserved  almost  exclusively  for 
specialists.      It  is  illustrated  here  (fig.  467  to  478). 

5"'.  Case  —  The  Treatment  of  Abscess  in  Hip  Disease 

The  treatment  by  puncture  and  injection  is  the  only  rational  one. 

AA  e  have  explained  the  technicpie  at  length  at  the  commen- 
cement of  this  Avork,  in  Chapter  in. 

Here  are  some  indications  relating  particularly  to  the  treat- 
ment of  abscess  in  hip  joint  disease. 

I.  Afli  r  being  certain  tliat  anlcvlosis  is  complete. 


464 


HIP    JOLXT    DISEASE. 


TREATMENT     OF    ABSCESS 


A  few  precautions  to  be  taken  accordincj  to  the  situation  oj 
the  abscess. 

When  the  abscess  is  at  a  distance  from  the  vessels,  there  is  no- 
thing in  particular  to  notice ;  but  ^vhen  the  abscess  in  situated 
either  in  front,  in  the  region  of  ihe  femoral  vessels,  or  aboA'e  the 
crural  arch,  in  the  pelvis,  there  are  some  special  points  to  consider. 


Fis.    'a'jC^.    —    Punclure  on   the    outside   of  the   vessels.     The  operator    isolates   the 
vessel  with  one  hand,  whilst  he  punctures  with  the  other  hand. 

a.      Beloav  the  crural  arch.  (fig.  479)- 

First  palpate  the  femoral  artery  Avhich  you  can  feel  pulsating; 
on  the  inner  side  of  the  artery  is  found  the  vein,  for  Avhich  you 
will  alloAv  a  centimetre  and  a  half,  lou  Avili  examine  Avhere 
you  ought  to  approach  the  abscess,  Avhelher  it  is  outside  the 
artery  or  inside  the  vein.  That  depends  on  the  facility  with 
which  pressure  by  the  fingers  makes  the  purulent  collection 
bulge  more  stronglv  and  more  distinctly,  on  the  outer  side  or 
the  inner  side  (fig.  kSo  and  following). 

When  you  have  decided  where  the  puncture  is  to  be  made, 


iiu:vT\ii:.\x   oi-   abscess   i>    mi'   ihseasi;  /|05 


Fi"'.  .'i8o.  —  Small  abscess  in  IVonl  of  llic  femoral  vein.  —  Fig.  .'i8i.  The  abscess 
is  pushed  inNvards  by  pressure  of  the  finger.  The  needle,  directed  inwards, 
against  the  dorsal  aspect  of  the  linger,  runs  no  risk  of  touching  the  vein. 


Fig.  '182.  —  i".  An  abscess  situated  behind  the  vessels.  —  Fig.  /|83.  —  2°^  A 
finger  firmly  presses  the  skin  on  the  inner  side  of  the  vein  in  the  direction  of  the 
arrow.  The  abscess  is  made  to  bulge  on  the  outer  side  of  the  artery,  which  is 
protected  with  a  finger  during  the  puncture. 


*^ 


Fig.  484.  —  Abscess  of  the  buttock.  —   It  is  easy  to  avoid  the  sciatic  nerve  which  is 
situated  at  an  equal  distance  from  the  trochanter  and  the  ischium. 

Calot.   —  Indispensable  orthopedics.  3o 


466 


HIP-JOI>T    DISEASE. 


TREATHEM    OF    ABSCESS 


internally  or  externally,  your  assistant  attempts  to  pass  his  finger 
under  the  vessels,  on  the  side  opposite  to  that  you  are  going  to 
puncture,    and  he    ^\[\{    push    the    collection    towards   you;   it 


Fig.   4S5.  —  Multiple  fislulae  (see  following  figures). 

becomes,    by    this    manceuvre.    more    easily    accessible.     You 
avoid  in  this  way  Avounding  the  vessels  (fig.  48o  to  483). 


Fig.  ^86.  —  Injeclion  into  the  fistulous  tracks  by  the  posterior  route.  The  modi- 
fying liquid,  injected  through  A  into  the  articular  cavity  returns  by  the  fistu- 
lous orifices  -which  one  blocks  with  a  large  tampon.  One  has  followed  here  the 
external  route  in  order  to  penetrate  into  the  joint  instead  of  the  anterior  route 
indicated  on  p.  SgB.  —  But  one  may  follow  also  the  anterior  route. 

Suppose,  however,  you  do  wound  them  :  at  once,  a  jet  of 
blood  issues  through  the  needle;  v\"ithdraw  it  immediately  and 
place  your  fmger  over  the  orifice,  pressing  for  a  moment,  then, 
as  in  dressing  a  phlebotomy  of  the  arm  (it  is  in  fact    the  same 


TREATMENT    OF    ARSCESS    IN     Mil'     DISEASE 


467 


tiling)  apply  a  lainpon  of  collon  wool  over  llic  bleeding  point 
Avilh  some  lurns  of  Velpeau  bandage.  The  slighllv  compressive 
dressing  will  be  removed  aflcr  five  or  six  days;  after  wbicli  you 
will  recommence  your  punctures,  going  a  little  further  aNNay 
from  the  vessels,  eitlier  inAvards  or  outwards. 


Fig.    ^87.   —  Diessiag    after  injection.  Fig.    '188.    —    2"'.    An    assistant   keeps 

i".  Two  tampons  are  placed  crosswise  hold  of  the  tampons  whilst  the  bandage 

over  the  fistula  to  keep  it  closed.  is  applied.      This  will  assure  the  obli- 

teration of  the  fistula  from  one  injec- 
tion to  the  other. 

b.  Above  the  crural  arch. 

An  assistant  causes  the  purulent  collection  to  bulge  more 
strongly  by  pressure  exerted  from  above  on  the  internal  iliac 
fossa.  You  keep  close  to  the  crural  arch  with  your  needle,  to 
be  sure  you  avoid  the  peritoneum,  and  you  keep  to  the  outside 
of  the  vessels  or  inside  of  them,  as  tlie  case  may  be  (v.  also 
fig.  819  to  822). 

c.  Behind  the  thigh  (fig.  /i84). 


468 


HIP- JOINT    DISEASE.     TECIIMQUE    OF    RESECTIO:^ 


lou  Avill  avoid  the  sciatic  nerve  by  remembering  that  it  passes 
obviously  at  an  equal  distance  from  the  trochanter  and  the  ischium . 

Q'^  Case.  —  Treatment  of  a  Fistula   in   Hip  Disease. 

The    treatment    should    be     suggested    by    that    described 

(Chap,  in  and  v)  for  fis- 
tulae  in  general,  and  for 
the  fistulae  of  Pott's  di- 
sease (v.  fig.  485  to  488). 
—  But  here,  in  the  hip 
Tensor  joint,  One  may  do  more> 
Drainage,  Arthro- 
tomy  and  Resection  of 
the  Hip  Joint. 

We  have  mentioned 
(p.  38 1 )  the  respective 
indications  for  these. 

Drainage  is  effected, 
as  everyAvhere  else,  by 
means  of  incisions  made 
at  all  the  points  Avhere 
one  suspects  there  is  pus 
retained. 

Arthrotomy,  or  the 
simple  opening  of  a  joint, 
is  performed  as  in  the 
four  first  stages  of  resection  of  the  hip  joint  and  is  terminated 
by  a  thorough  drainage. 

We  will  proceed  to  explain  the  technique  of  resection. 

Resection  of  the  Hip  joint'  (fig.  489  to  495). 

i^'  STEP.  —  Incision  of  the  skin  along  a  line  running  from  the 
anterior  superior  iliac  spine  to  the  antero-superior  angle  of  the 


Fig.  489.  —  Sketch  of  tbe  incision,  either  for 
drainage  of  the  joint,  or  for  resection.  One 
sees,  at  the  bottom  of  the  wound  the  space  which 
separates  the  Gluteus  Medius  from  the  Tensor 
Fasciae. 


I .  Tlie  indications    for   which  are  SO  exceptional,    as  you  will  not  have 
forgotten  (v.  p.  38 1). 


RESECTION    (W    TIIK    111!'  .lOlM' 


469 


trochanter,  exceeding  by  two  centimelrcs  in  cacli  dircclion  these 

two  extreme  points. 

2„,i  j..rpp,  __  rind  Ihc  Inlcrral  bet\\con  the  tensor  fascias  and 
Ihe  ^hilcus  medius  and  sopaialr  their  luo  edges.     If  the  interval 


Great  troch. 


Fig.  igo.  —  One  finds  one's  way  througli  the  interspace  and  sees  tlie  capsule  of  the  joint. 

is  not  recognizable,  Avhich  is  the  case  in  old  standing  suppu- 
rations about  the  hip-joint,  cut  in  the  direction  of  the  cutaneous 
incision,  through  the  lardaceous  tissues,  down  to  the  capsule. 

^rd^^^j,  _  Exposure  of  the  capsule,  ovoi^\hiiisti\\Tema.ms  of  It. 

4th  g.j,j,p_  —  Opening  of  the  capsule  by  a  crucial  incision.  — 
The  head  of  the  femur  appears. 

5ti.  STEP.  One  raises  the  head  without  dislocating  the  femur. 

If  the  head  is  completely  necrosed  or  in  a  soft  condition,  as  is 


470 


HIP- JOINT    DISEASE.     RESECTION    OF    THE    HIP- JOINT 


frequently  the  case  in  hip-joint  disease,  one  removes  it  entire- 
ly with  a  curette,  and  lays  bare  the  acetabulum.  If  the  head 
of  the  femur  is  not  necrosed  nor  softened,  one  removes  (with 
the  chisel,  forced  in  by  the  hand  or  the  mallet)  only  the  upper 


Fig.    /.gi. 


Head  ol     f. 


Neck. 


Caps,    opened. 
Great  troch. 


( — -J  ■j'^i^<-^.-i'<^'^'^- 


Arlhrotomy.     The  capsule  of  tlie  joint  is   opened  in   its  entire  length 
and  allows  the  head  and  neck  of  the  feniuv  to  be  seen. 


half  of  the  head  and  neck,  to  ensure  the  discharge  of  the  pus; 
we  will  find  the  half  remaining  extremely  useful  from  an 
orthopoedic  point  of  view  for  preventing  ulterior  luxations. 

6'*  STEP.  —  One  makes  the  toilet  with  a  curette,  then  with  gauze, 
with  which  one  rubs  out  the  cotyloid  cavity  and  neighbouring 
parts  in  order  to  remove  all  debris.      Then  one  ensures  hsemostasis. 

I  ought  to  make  special  mention  of  the  arrest  of  haemorrhage 


TEC.HMQLK    OT    lU'.SEC.I'lON    Ol-      llli:    llll'-.IOlM 


A7' 


Fig.  iqa.  —  The  upper  part  of  Ihe  head  and  neck  have  been  scraped  which  is  some- 
times sufficient  to  ensure  the  drainage  of  the  cavity. 


during  or  after  the  operation. 
You  should  see  to  this  at  every 
step. 

It  is  necessary  to  proceed 
quickly,  —  that  is  understood. 
But  there  is  one  thing  of  more 
importance  than  going  quickly 
( the  tiito  hefore  the  cito)  :  it  is  to 
see  that  the  patient  does  not 
lose  blood,  or  loses  as  little  as 
possible. 

For   this,  at  each   step  of  the     Fig.    '193.  —  Reseclion  of  upper  half  of 

operation,  one  secures  the  small         }'   'trochanter,  of  the   head  and  neck, 

r  '  by  means  of  a  cold  chisel  pushed  in  by 

vessels   which  may  have  been       the  hand. 


473 


HIP-JOINT    DISEA.se. 


RESECTION    OF    THE    HIP-JOINT 


opened.  As  to  the  oozing  from  the  surfaces  of  the  soft  parts  and 
the  bone,  one  meets  that  with  tampons  and  ^vith  firm  pressure 
upon  the  parts  for  one,  two,  three,  four,  five  minutes,  until  no 
more  blood  flows.  I'hen,  one  proceeds  a  step  further,  one 
compresses  again,  and  so  on. 

II  vou  have  been  careful  to  prevent  bleeding,  the  shock  of 


Great  trocli. 


Fig.  liQfi.  —  Complete  ablation  of  the  head  and  neck.  —  A  cold  chisel,  worked  by 
hand,  divides  the  neck  near  its  base  and  nearly  perpendicularly  to  its  own  axis. 

the  operation  will  be  almost  nil,  even  in  an  operation  of  half  or 
three  quarters  of  an  hour;  on  the  contrary,  the  shock  will  be 
grave,  even  after  a  short  operation,  if  you  have  not  controlled 
the  bleeding  well. 

At  the  end  of  the  operation,  one  makes  a  permanent  arrest 
of  haemorrhage  by  pads  placed  in  the  bottom  of  the  aceta- 
bulum and  by   energetic    pressure,   which  one  keeps  up  for 


TI.CIlMdlE    OF     UESK'niON 


'.73 


iVom  10  to  12  minutes  hclMiv  pnu-ccdin,-  In  llir  <lrcssin^'. 
Olio  or  Iwn  l.ii;-v  (liaiii;i,-c  lubes  are  iii-erled  into  llie  JmiiiI, 
and.  if  lli(M-e  is  room,  into  the  liok  in  ihc  roi.l'  (.1'  the  cotyloid 
caNilN.  enlarged  if  necessary;  and  one  arranfics  round  llic  drai- 
nao-e  lube  several  tampons  of  collon  wool  lor  l\\enl\  lour 
hours.      One  suliires  llic  two  exlremlties  of  iIh'  wound. 


Fig.  !iC)b.  —  Exploration  of  the  cotYloid  cavity  after  abrasion  of  the  Lead. 

y**"  STEP.  —  The  apparatus.  —  One  constructs  over  the 
dressing  a  large  plaster,  Avith  the  hmb  in  a  position  of  exten- 
sion and  slight  abduction. 

The  next  day,  one  cuts  out  a  sqxiare  opening  opposite  to 
the  region  of  the  operation,  following  as  a  guide  the  line  of  the 
incision,  and  one  removes  the  tampons,  having  previously  mois- 


474 


HIP-JOIXT    DISEASE.     RESECTION 


tened  them  with  oxygenated  water.      From  that  time  onwards 
the  dressings  are  changed  through  the  opening  in  the  plaster. 

The  technique  of  resection  varies  a  little  if  it  is  done  for 
one  of  those  cases  of  hip-disease  which   go    on  indefinitely 

in  the  form  of  dry  caries  (v.  6""  case)  because  there  one  looks 


Fi£ 


L^f^- 


I96.  —  Drainage  after  abrasion  of  the  Lead  and  part  of  tlie  neck  of  the  femur. 
The  drain  passes  into  the  perforation  in  the  roof  of  the  acetab    um. 


for  a  complete  and  immediate  cure  of  the  disease,  that  is,  union 
by  first  intention. 

In  this  case,  proceed  as  in  resection  of  the  knee  joint  for 
W'hite-swelling  not  opened.  Guard  Avith  more  care  than  ever 
against  any  defect  in  asepsis.  Remove  by  abrasion  all  the 
suspected  points  of  the  tAvo  osseous  extremities  and  of  the  sur- 
rounding soft  tissues. 

AYith  regard  to  the  bones,  hoAvever.  endeavour  to  reconcile 
the  necessity  of    removing  all  the   diseased  portions  with  the 


Illl'-.IOIM      DIMASi:.    CONVAI.ESCENCE 


'.7^> 


on 

ic- 
ilh 


closirablc  prescrNalimi  of  a  jiorlioii  of  tlic  Ik'.mI.  or  ,il  lc;isl 
the  neck.  surCu-'uMil  lo  provide  a  solid  suppoii  \'>>y  \\u'  liml) 
a  level  \\  illi  llie  aiclaludum. 

Oncloiiclies  ihc  osseous  sniTaces  willi  a  strong  solution  oi'p 
nol  (one  to  ten  for  instance) and,  for  ten  minutes,  apply  pads  w 
very  energitic  pressure  on  llie  os- 
seous surfaces  in  order  to  ensure  h;e- 
mostasis  before  closing  the  \vound. 

You  will  not  close  it  completely 
but  will  insert  two  small  drains  at 
the  two  extremities  oftheAvound  to 
prevent  the  formation  of  a  hicma- 
toma,  which  so  easily  becomes  in- 
fected. The  drains  are  removed  at 
the  sixth  or  eighth  day. 

CONVALESCENCE  AFTER 
HIP-DISEASE 

AYlien  do  you  place  the  child 
on  his  feet.^^ 

As  a  general  rule,  when  the 
tuberculous  focus  in  cured. 

One  may  consider  it  as  cured 
6  or  lo  months  after  the  disappear- 
ance of  the  clinical  manifestations: 
fungosities,  sol^tening  and  pain, 
either  spontaneous  or  on  pressure. 

Then'  the  child  is  placed  on  his 
feet ;  at  the  beginning,  with  the  support  of  two  crutches  (or,  better 
stih,  held  by  the  hands)  then  of  two  sticks  (fig.  497),  llien  of  a 
single  stick  or  rather  of  a  walking  stick  held  on  the  side 
opposite  the  affected  hip. 

I .    From    tliis    lime,    he    is   permitted    to    sit  up  in  bed  for  i  or  2  liours 

a  day  ;  4  to  6  months  later,  he  will  be  able  to  sit  in   an  ordinary    chair    to 

take  his  meals  (without  the  apparatus). 


Fig.  497.  —  Tlie  sticks  which  ad- 
vanlageously  talie  the  place  of 
crutches  during  convalescence 
after  hip  disease. 


476  CELLULOID    APPARATUS    FOR    HIP    DISEASE 

He  will  do  his  walking  exercises  from  ten  o'clock  in  the 
morning  till  six  o'clock  in  the  evening. 

He  will  Avalk  5  minutes  every  2  hours  for  the  first 2  months', 
5  minutes  an  hour  for  another  2   montlis,  then   10  minutes  an 


Fis;.  .'198. —  Tlie  sma'l  apparatus  in  eel-  Fig.  ^gg.  —  The  same.      Poilerior 

luloid  padded  and  furnished  -wilh  an  aspect, 

armature  of  steel.      Anterior  aspect. 

hour  the  4  months  folloAving,  after  wliich  he  will  have  returned 
to  the  normal  regime. 

Apparatus  for  convalescence. 

i^'  CASE.   —  If  the  hip  has   preserved   the   whole,   or   the 
greater   part   of   its    movements   a    removahle    apparatus    in 

I.  In  the  interval  of  these  exercises,  the  child  wild  rest  on  a  frame  or  on 
a  couch. 


CEI.I.l  l.'ill)    AI'I'All.VTI  S     IN     Mil'     hISl'ASE  '\-~ 

collulwid  i-  wniii  h\  llic  |);iliciil  wlirii  he  makes  his  first 
attempt  at  walking.  Tlic  a|.|ui;itiis  will  he  llic  mii;iII 
one  stopi)"!!!^  al  llic  knee  (lig.  '\\)X.  \[)\)).  -  "i'-  li'H' r.  llic 
large  apparatus  rcacliing  lo  llie    Inoi.  hul    joiiilcd    al    the  kiicci 


Fig.  Boo.  —  The  large  apparatus  in  cel- 
luloid jointed  at  the  knee  and  ankle. 
Anterior  aspect. 


Fig.  5oi.  —  The   same. 
Posterior  aspect. 


and  ankle  (fig.  ooo,  5oi).  —  The  patient  Avill  ^vear  it  only 
from  lo  a.  m.  to  6.  p.  m.  His  hip  will  he  free  all  the  rest  of 
the  time  as  well  as  during  the  night. 

6  to  10  months  later,  one  will  commence  to  massage  the  legs 
gently,  electrise  them,  bathe  them;  and  one  teaches  the  patient 
to  walk  properly,  methodically,  "  thinking  out  "  each  step. 


478  CELLULOID    APPARATUS    I>i'    HIP    DISEASE 

After  a  year,  all  apparatus  may  be  put  away. 

2°"^  CASE.  — If  the  patient  has  a  stiff  hip  Avith  a  tendency 
to  deviation,  he  must  wear  the  apparatus  constantly. 

It  should  be  a  small  irremovable  plaster,  or  a  large  cellu- 
loid reaching  from  the  umbilicus  to  the  foot,  jointed  at  the  knee 
and  at  the  ankle. 

For  how  long  is  the  apparatus  to  be  worn  ? 

You  will  leave  on  the  apparatus  until  the  hip  has  no  ten- 
dency to  deviate,  which  result  is  often  not  attained  until 
2  years  or  even  longer,  after  standing-up  has  been  first  allowed. 

When  you  judge  that  the  time  has  arrived  to  leave  off  the 
apparatus,  you  leave  it  off  gradually,  first  at  night,  then  part 
of  the  day,  and  you  will  verify  very  exactly  every  8  days  that 
there  has  been  no  movement,  that  is.  that  there  is  no  return  of 
adduction  of  the  knee  nor  lumbar  hollowing.  If  you  perceive 
the  least  deviation,  replace  the  apparatus  or,  at  least,  ensure 
during  the  night,  by  the  help  of  Velpeau  bandages,  attitudes 
contrary  to  those  Avhich  the  limb  has  a  tendency  to  assume. 

lou  will  combat  adduction,  flexion,  rotation,  in  the  way 
mentioned  in  chap,  xiv  (fig.  85o  to  854). 

And  even  in  the  case  where  nothing  has  yielded,  apply  slight 
extension  during  the  night,  as  a  preventive  measure,  so  that 
the  limb  keeps  the  attitude  and  the  length  you  Avish  it  to  retain. 
Coxalgic  children  have  need,  after  the  cure  of  the  tubercu- 
losis, of  being  looked  after  by  the  surgeon  for  one  or  even  seve- 
ral years,  without  Avhich  they  very  often  again  become  grad- 
ually deformed.  \ou  have  cured  a  child  Avithout  deA^ation, 
with  no  lameness  or  nearly  none;  the  parents  think  it  is  no 
longer  necessary  for  you  to  see  him,  and  then,  after  one,  two 
or  three  years,  a  deviation  of  the  hip  and  a  marked  shortening- 
have  recurred,  causing  a  A^ery  unsightly  lameness. 

Do  not  give  up  these  children  because  they  haA^e  giAen  you 
up  too  soon.  Put  them  back  under  treatment  and  redress  the 
dcAdation,  in  the  Avay  Ave  have  directed  for  vicious  ankyloses  in 
cured  hip  cases  (v.  p.  447)- 


This   imroiliinali'  ('\(iilii,ilil  \    will   noi  (icciir  if  \(ui   kmih'Iii 
\)vv   III    nv'jic    llic    parents   [n    show   llic    child    lo    you    allcr    lh( 


Fig  002.  —  To  take  llie  measuremenls 
for  a  special  heel.  The  patient  is 
phiced  upright.  The  iliac  spines  at 
the  same  level :  one  places  some  pla- 
ster under  the  sole  of  the  foot  -which 
does  not  touch  the  ground. 


Fig.  5o3. — The  foot  resting  on  the  spe- 
cial heel  is  covered  with  a  stocking, 
the  mould  is  made  over  the  whole  ;  one 
sees  the  band  of  zinc  over  which  will 
be  made  the  incision  to  take  off  the 
nesative  mould. 


Fig.    5o.'i .    —   Boot  for  the  affected  side. 
Foot    pro\ided  with"spccial_heel. 


Fisr.  5o5.  —  Sound  side. 


apparatus   has    been  left   off,  at  least  every  3  or  4   months   for 
several  years. 


48o  HIP    DISEASE.    RELAPSES    AAD    RECURRENCES 

Orthopoedic  Boots. 

A  shortening  will  often  remain\  in  spite  of  everything^. 

If  that  amounts  to  less  than  2  c.  m.  it  is  negligible;  the  child 
will  walk  well,  without  even  the  need  of  a  raised  boot  (provided 
the  position  is  good  and  the  hip  well  united).  But  if  the  shorte- 
ning attains  or  exceeds  3  cm.  supply  a  special  heel,  not  equal 
to  the  height  of  the  total  shortening,  but  only  half  that.  The 
boot  should  be  supple  to  preserve  the  easy  movements  of  the  foot. 

Relapses  and  recurrences'. 

In  stating  the  precautions  to  take  and  the  care  to  be  given 
to  patients  just  allowed  to  stand  again  and  during  convales- 
cence, we  have  implicitly  indicated  the  best  means  of  avoiding 
relapses,  that  is  the  return  of  the  tuberculosis. 

We  ought  to  add  some  precautions  of  a  general  nature, 
meaning  by  that,  that  one  must  not  be  in  a  hurry  to  send 
back  a  child  to  Paris  or  to  any  great  city,  or  to  the  poor  sur- 
roundings where  he  was  taken  ill. 

One  must  keep  him  by  the  sea  or  in  the  country,  and  attend 
to  his  diet  and  to  his  hygiene. 

Keep  him  from  every  possible  contagion. 

How  many  cases  of  cured  hip  disease  have  broken  down 
when  prematurely  sent  back  to  Paris  1 

Do  not  forget  that  cured  hip  disease  is  an  old  tuberculosis 
and  the  subject  of  it  ought,  on  this  account,  to  foUoAv  a  severe 
course  of  hygiene,  for  several  years  more. 

Thanks  to  good  supervision,  one  will  avoid  relapse,  or  at  least 
one  wall  render  it  as  rare  as  is  humanly  possible ;  for  one  must 
admit  that  a  debilitating  malady  which  has  unfortunately 
appeared  a  short  time  after  the  cure,  —  influenza,  diphtheria, 

I.  Particularlv  in  hip  disease  "VAith  abscess,  the  tuberculosis  having,  in 
these  more  serious  cases,  deeply  eroded  and  sometimes  destroyed  the  head  of 
tlie  femur  and  the  roof  of  the  acetabulum. 

3.  Unless  you  have  made  early  articular  injections. 

3.  What  we  say  here  of  recurrences  in  hip  disease  is  applicable  to 
recurrences  of  other  osteo-articular  tuberculoses. 


BELAPSF.S    AND    REiiT  UUF.NCF. 


iniiiiins.  etc.  Ilia  violciil  traumatism  over  lli<- hip.  iua\  [iiecipi- 
lale  a  ielai)se.  whatever  iiia\  have  been  dour  up  \o  this  moineiil. 
Parents  ought  lo  flee  from  all  foci  of  coiilagioii  and  preserve 
their  ehildrcii  Avilli  the  greatest  care  from  all  kinds  of  shocks. 
What  to  do  in  the  presence  of  a  patient  with  hip- 
disease  cured  for  one  or  two  years,  who  suffers  again  in  the 
region  of  the  joint? 

Assure  vourself  first  of  all   that  it  is  a  question  here  of  a  true 
relapse  and  not  of  some  passing  pains  due  to  a  simple  sprain 
—  coxalgiques  assuredly  being  liable  (as  much  or  even  more  than 
anyone  else)  to  a  sprain  of  the  hip  after  a  blow  or  some  exaggerated 
joli.rue  —  not  leading  inevitably  to  a  return  of  the  tuberculosis. 
In  case  of  doubt,  always  place  the  child  at  rest  for  two  weeks. 
If  all  pain  disappears  the  same  day,  replace  the  child  on  his  feet 
after  those  two  weeks  and  send  him  back  again  to  his  ordinary 
life,  but  little  by  little,  watching  over  him  very  closely,  of  course. 
On  the  other  hand,  if  the  pains  reappear  as  soon  as  he  is  placed 
6n  his  feet,  or  if,  at  the  outset,  he  has  been  taken  Avith  acute  pains, 
muscular  contractures  in  the  whole  of  the  region,  or  with  noctur- 
nal pains,  or  again,  if  there  exist  fungosities  appreciable  on  pal- 
pation, vou  will  conclude  he  has  a  true  relapse  and  will  submit 
the  child  to  the  same  treatment  he  underwent  at  his  first  attack. 
Let  us  mention   that  the  appearance  without  any  pain,  of  a 
periarticular  abscess,  two,  three,  four  years  after  the  child  has 
been  sent  back  to  normal   life,   is    not   always  the  sign   of  a 
relapse  of  osteo-arthritis.      It  is  a  question  very  often  of  an  old 
erratic  bacillarv  nodule,  of  a  fungosity  of  the  soft  parts,  having 
lost  for  a  long  lime  all  communication    with   the   hip,    Avhich 
could  have  been  reabsorbed  and  remained  permanently  ignored, 
and    which,    instead    of   that,   has  softened  and  produced    the 
abscess  of  which  Ave   speak.      In   a  word,   it    is    an   idiopathic 
abscess  of  the  soft  tissues,  rather  than  an  abscess  by  gravitation 
coming  from  the  joint.      You  will  puncture  it  and  inject  it.  and 
vou    will   be   able  to  send  back   the  child   almost  immediately 
(after  a  month  or  two)  to  his  ordinarv  life. 

Calot.  —  Indispensable  orthopedics.  ^' 


482    HIP   DISEASE.    I*''.    AN    OBSERVATIO>"    OX   RECENT    II IP   DISEASE 


APPENDIX  TO  CHAPTER  III 

On  our  results  in  hip  disease. 

i^'.  Specimen  of  the  result  usually  obtained  in  cases  of  recent 
hip  disease  fv.  figs.  5o6  and  007). 

The  case  here  iUustrated  is  that  of  a  little  boy,  Pierre  R...  of 
Paris,  Avliom  yse  treated  at  Berck  for  a  left  coxitis  of  between  two 
and  three  months  standing. 


Fig.  5oG.  —  Child  cured  of  left  hip- 
disease,  Pierre  R...  of  Paris  who  was 
sent  to  Berck  by  my  master,  ^I.  Ja- 
lajruier. 


Fig.  507.  —  The  same.  Oae  sees  that 
he  has  recovered  the  -whole  of  his  mo- 
vements. He  is  able  to  flex  his  thigh 
at  an  acute  ano;le. 


These  Iwo  photographs  were  taken  three  years  after  cure. 

The  diagnosis  had  been  made  by  my  master,  M.  Jalaguier,  who 
had  even  commenced  the  treatment  in  Paris,  before  sending  the 
child  to  Berck. 


AN    ORSRRVATION    ON    GUAVK    HIP    DISEASE 


/,83 


Al  Bcrtk.  llu"  lllllc  [laliL'iiL  I'ollowed  llic  IreaUncul  given  in  lliis 
book  1(11-  lii[)  disease  ol'  the  llrst  variety.  Al  the  end  of  i4  months, 
he  A\as  allowed  to  get  up  and  begin  to  walk.  Here  are  the  photo- 
grapiis  taken  three  years  later. 

The  lirst  shews  that  the  child  is  quite  straight  (iig.  5oG).  No 
hollowing,  no  deformily,  no  shortening.  The  second  shows  that 
he  has  recovered  the  whole  of  his  movements. 

After  that,  one  will  not  be  surprised  that  the  child  walks  to-day 
without  a  shadow  of  a  lameness.  He  is  a  normal  child.  And 
similar  results  arc  not  the  exception,  they  arc  the  rule  in  hip  disease 
taken  at  the  beginning  and  well  treated.  We  can  recall  a  good 
number  of  our  old  cases  of  hip  disease  Avho  have  been  able  to  go 
through  their  military  service. 

2"''.  Specimen  of  the  results  obtained  in  old  or  grave  cases  of 
hip  disease. 

The  four  figures  (5o8  to  5io)  represent  a  boy  of  i3  years  of  age 
(A.  de  N.  of  Lisbon)  who  came  to  us  at  Berck  in  1899,  with  a  left 
hip  joint  disease  of  malignant  character  dating  from  about  4  years 
and  still  in  active  progress ;  the  child  complained  of  very  severe 
pains  and  presented  Iavo  large  abscesses,  one  on  the  buttock,  the 
other  in  the  middle  part  of  the  thigh,  but  not  yet  opened,  fortuna- 
tely. There  was  impossibility  of  movement  without  crutches,  on 
account  of  the  pain,  and  of  a  very  marked  deviation  of  the  affected 
thigh,  which  was  flexed  at  nearly  a  right  angle  S  with  adduction  and 
internal  rotation. 

General  condition  very  indifferent,  child  pale  and  miserable. 

Treatment.  —  Complete  repose  in  the  recumbent  position,  on 
a  frame.  We  commenced  bv  treating  the  abscesses  —  punctures 
and  injections  —  without  taking  notice  of  the  hip  joint  disease.  At 
the  end  of  three  months,  the  abscesses  were  dried  up  and  at  the 
same  time  the  general  condition  Avas  greatly  improved.  At  that 
moment  we  commenced  orthopoedic  treatment,  that  is,  the  correc- 
tion of  the  vicious  ankylosis,  proceeding  gently,  without  chloroform, 
and  by  stages,  in  the  following  way  :  the  trunk  of  the  child  being 
held  by  two  assistants,  we  made  slight  traction  of  about  10  or 
1 5  kilograms,  on  the  foot  and  the  leg  and  after  2  or  0  minutes  of 
this  traction,  having  obtained  from  10  to  iS''  of  correction,  we 
stopped  there.     Handing  over  the  traction  to  an  assistant,  we  plas- 

I.  If  the  thigh  appears,  in  figure  5o8,  much  less  tlexecl,  it  is  because  the 
lumbar  hollow  is  not  obliterated,  but  the  flexion  attained  80°  or  90°  Avhen  one 
had  taken  the  precaution  of  obliterating  the  lumbar  arch  (v.  p.  48^.  fig.  5o8). 


484 


HIP    JOINT    DISEASE. 


AN   OBSERVATION    ON   AN   OLD    CASE 


tered  the  child  in  this  sHghtly  corrected  position  (large  plaster  going 
from  the  umbilicus  to  the  toes). 

A  fortnight  later,  a  second  correction  (again  without  chloro- 
form) of  io°  to  i5",  and  a  second  plaster,  and  so  on;  every  two 
"weeks  a  new  short  sitting  for  correction,  —  always  gentle,  so  as  not 


Fig.  5o8.  — Left  hip  disease  dating  back 
fourjears,  of  grave  character,  and  still 
in  active  progress.  Severe  pains,  two 
abscesses,  vicious  ankylosis.  The  child 
unable  to  move.  Such  was  the  condi- 
tion of  child  on  arrival  at  Berck. 


Fig.  5o8  bis.  —  The  same  child  three 
years  later  (the  abscess  has  been  dried 
up  and  the  deviation  obliterated  in 
several  sittings,  by  stages).  See  the 
text  for  details  of  treatment. 


to   fatioue  at  all  the  child  who  bore  these  very    small    interferences 

o  ^ 

admirably. 

At  the  end  of  three  months,  three  fourths  of  the  correction  was 
obtained.  To  complete  the  correction  we  preferred  to  have  recourse 
to  chloroform  and  perform  a  tenotomy  on  the  adductors.  This  very 
small  operation,  which  lasted  barely  5  minutes,  gave  us  not  only 
the  complete  correction,  but  even  a  hvpcr-correction  of  from  35"  to 


nil    TWO    AltSCESSES    AND    VICIOLS    ANKYLOSIS 


/|85 


l^o^\  Tlii>  liiuc,  we  Irll  llic  j)la<l('r  in  posilidii  I'm-  lour  inoiillis. 
TliiMi  a  ni'w  largv  |ila<l('i-  lor  lliroo  montlis.  willi  a  siiiallor  ai)(luc- 
lioii  (2.')  to  .'nil.  Allci-  Ihal  a  llnal  i)la;>lcr,  whirli  slopped  al  llie 
kiuM'.  in  an  aiidnclioii  of  luj"  only.  For  one  year  more,  the  cliild 
wore   small    plasters:   and  llien  lor  nearly  riglil    nionllis  a   celluloid 


Fig.    009.  —    The  same    child   seen 
profile  (on  his  arrival  at  Berck). 


Fig.  5io.  —  The  same,  three  years  after 
our  treatment.  Observe  the  straigh- 
tening. The  good  attitude  has  been 
maintained    for  the    last    seven  vears. 


apparatus,  Avhich  makes  a  duration  of  about  three  years  for  the 
whole  of  the  treatment.     But  look  at  the  result  obtained. 

The  child  Avalks  actually  without  apparent  lameness,  and  this 
slowlv  obtained  cure  has  been  perfectly  maintained  for  the  last  seven 
years. 

One  can,  Avith  a  treatment  well  conceived  and  well  carried  out 
obtain  results  in  every  way  as  satisfactory  in  the  immense  majority 
of  cases  of  grave  and  far  advanced  hip  disease. 


CHAPTER   VII 


WHITE-SWELLINGS 


I.  —  Diagnosis  of  tuberculous  arthritis  at  the  onset. 


We  do  not  speak  of  the  disease  when  the  diagnosis  obtrudes  itself, 
but  at  the  commencement  of  the  disease. 

You  are  consulted  about  a  patient  -who 
experiences  in  one  of  his  limbs  a  fatigue, 
or  a  pain  (the  pain  sometimes  only  at  night), 
or  even  a  single  functional  inconvenience, 
Avhich  may  be  only  intermittent.  Never 
neglect  to  examine  completely  nude  in  such 
cases,  the  regions  of  the  joints  of  the  suspec- 
ted member,  comparing  them  constantly 
Avilli  the  same  regions  on  the  opposite  side. 
—  Find  out  : 

i^^  If  there  exist  pain  on  pressure  of 
the  articular  extremities  in  the  segment  over 
Avhich  the  patient  or  his  friends  dra^v  your 
attention  (fig.  on). 

2"''.  If  there  exist  already  a  commencing 
deviation,  and  in  default  of  an  apparent 
deviation,  a  limitation,  however  slight,  of 
tlie  movements  of  this  articulation. 

With  these  two  signs  you  Avill  be  able 
to  assert  that  there  is  "  something  wrong  " 
in  the  joint  (fig.  5i2,  5i3,  5i4,  5i5). 

HoAv  will  vou  know  that  this  ' '  some- 
thing "  is  tuberculous? 
i'^  By   the  history-     If  the  pain  and  loss  of  power  have  super- 
vened without  appreciable  cause,  without  a  distinct  injury,  without 
rheumatism,  Avithout  blennorrhagia,  without  the  antecedents  of  scar- 
latina or  of  hereditary  syphilis,  you  should  think  of  a  tuberculous 


Fig.  5i  I.  —  White  swelling 
of  the  knee.  —  Look  for 
pain.  The  painful  points 
(on  pressure  "with  the  index 
finger)  may  he  found  either 
opposite  the  epiphysial  car- 
tilasres  or  over  the  interline. 


DIAGNOSIS   .)l      11  UI.KCLLOUS    AUTlllUTlS    AT    Tllli   COMMENCEMENT       ^87 

ailhrills,  cspeciallN   il'  nou  arc  doallnj;  uilli  a  delicate  cl.ild.  or  one 


.-J~F 


Fi.  5,..  -  Umliailoa  ofmo.e,nents.-The  patient  Ivingon  l.ls  'j'";    «"  tl^e  ri.l^a^- 
^ed;  side,  tle.ion  oflhe  knee  is  very  limited  ;  on  the  left   .ouud ,  sule  llex.on  .,  normal. 

recoverhio-   from  a  debilUatlng  disease,  an   eruptive  fever,  measles, 


\\  liooping  couuli.  etc. 


^ddJe) 


Fig.   5i; 


Fis.  oiA. 


Fi£.  5i3^.  —  Lmitalion  of  movemenl.  —  A  normal  knee  joint.   —  Complete  extension 

is  possible, 
Ficr.  01^.  —  A  diseased  knee  joint.  —  Complete  extension  is  impossible,  it  remains  at 

°  a  slight  degree  of  flexion. 

Fio-.   5i5.  —  Front   view.   —  Globular   knee.     One  notes  at  the  same  time    a   slight 
decree  of  srenu  valgum. 


2"'.    By  the  direcl  sirjns.     If  the  patient  has  no  i'cver  (or  scar- 


488 


^YHITE    S^VELLINGS 


DIAGNOSIS    AT    THE    ONSET 


cely  a  few  tenths  of  a  degree) :  if,  on  palpation  of  the  accessible 
parts  of  the  synovial  membrane,  you  find  thickenings  (fig.  5i6, 
017),  irregular  bulgings  of  the  serous  cavity,  a  pastv  consistence  or 
pseudo-fluctuation  :  if  there  exist  an  atrophv  of  the  muscles  contrast- 
ing Avith  thickening  of  the  folded  skin  (fig.  342,  p.  060). 

S'"^.  By  the  positive  ophthalmo-readion,  the  value  of  Avhich  seems 
to  me  to  be  real  without  being  pathognomonic. 

In  the  cases  where  vou  still  have  some  doubt,  have  the  couraore 


*:^ 


Fig.  5 1 6.  —  ^Normal  knee.  Tlie 
osseous  prominences  and  the  mus- 
cles in  relief   normal  condition,. 


Fig.  517.  —  Diseased  knee.  The  osseous 
and  muscular  prominences  have  disap- 
peared ow  ing  to  swelling  of  the  knee. 


io  reserve  your  diagnosis ;  ask  to  see  the  patient  again  :  meanwhile, 
keep  him  under  observation  . 

If  vou  think  there  is  a  possible  sprain,  massage  it;  —  if  rheu- 
matism, prescribe  salicvlate  of  soda:  —  if  simple  hydrarthrosis, 
puncture  it  and  applv  pressure:  if  hereditarv  svphilis,  adopt  the 
specific  treatment. 

When,  in  spite  of  these  different  treatments  the  symptoms  still 
persist  for  several  weeks,  namelv,  pain  on  pressure  over  the  ends  of 
the  bones,  limitation  of  movements,  functional  distress,  thickening  of 


ouriioioinic    iiucAiMKM    oi     wiiin:   s\\i:ij.ings  /189 

[\\o  s\ii()vi;il  mciiibraiic,   —   lIuMi  coiicludc  [li;il   llicrc  i>  a   In  IxtiuIoiis 
iiillirili-  and  coniiuoiicc  llir  licalincnl  a|)|ii()[)riak'  to  llial  coridiliryn. 

//.  —  J*io(ino.<is  of  irhitc  sirclling  accurdunj   lo  tlw  vurii'lifs  tiiul  urcordinij 
Id  the  Ircatinciit. 

r'.  Will  it  be  cured?  —  ^  es ;  if  llie  palionl  lives  ])\  the  sea,  or 
in  llic  counlrv,  and  if  von  do  nol  open  or  allow  to  he  opened,  the 
tubcrcnlons  locus  in  llie  joint. 

2'"'.  How  will  it  be  cured?  —  It  is  always  possible  lo  preserve, 
or  to  give  back  lo  Ibc  patient,  a  limb  in  good  posilion,  —  strong 
and  useful. 

As  to  ihe  movements,  lliat  is  another  matter;  they  depend  on 
tiie  joint,  on  the  gravity  of  the  disease,  on  the  age  of  the  patient,  and 
not  only  on  the  treatment  adopted.  We  shall  see,  in  studying  wliite 
swellings  in  particular  (v.  p.  5 10),  what  you  can  safely  promise  as 
lo  mobility  in  eacli  variety  of  the  condition. 

3'"'.  When  will  it  be  cured?  —  This  depends  chiefly  upon  the 
treatment  adopted.  In  a  year,  with  the  intra-articular  injections: 
in  3,  4,  0.  or  G  years,  Avith  the  conservative  treatment  without 
injection;  in  3  or  4  months,  with  a  very  successful  resection.  So 
much  for  a  closed  white  SAvelling  (with  or  Avithout  elTusion).  But, 
if  it  happens  to  be  a  fistulous  white  swelling,  it  is  impossible  to  be 
precise  as  lo  the  duration  of  the  disease  (perhaps  however  one  may 
be  permitted  to  say  a  year  and  a  half  on  an  average  with  the  conser- 
vative treatment  here  indicated  and  in  surroundings  such  as  those 
of  Berck).  (See  the  observations  on  white  swellings  with  fistulae 
cured,  in  our  "  Traite  des  tiiineiirs  blanches  ",  Masson,  edileur,  1906.) 

TREATMENT  OF  WHITE-SWELLINGS 

i^t  PARTIE  :   GENERALITIES  APPLICABLE  TO  ALL  WHITE 
SWELLINGS. 

We  ought  to  make  a  distinction    betvAeen  the    orthopoeclic 
treatment  and  the  treatment  of  the  tuberculous  focus. 
A.—    ORTHOPCEDIC  TREATIVIENT. 

I'".  White  swelli>'g  benign  and  recent. 

(Little  or  no  fungosity,  AAithout  pain  and  without  devia- 
tion.) In  the  hospital,  and  for  children  of  the  working  class, 
you  will  at  once  apply  a  plaster  (a  circular  plaster  extending 
to  the  neighbouring  articulations). 


4gO  WHITE    SWELLINGS  :     CORRECTION    OF    DEFORMITIES 

For  town  children,  you  may  equally  well  use  a  plaster;  ne- 
vertheless it  is  better,  in  these  cases  and  in  this  class  of  people, 
where  you  always  look  for  a  cure  with  mobility  of  the  joint, 

not  to  apply  a  plaster,  provided  the  joint  affected  is  kept  at  rest. 

Prohibition  of  walking  and  rest  in  the  sitting  position  with 
the  leg   stretched   out.   if  the  lower  limb  is  affected. 

The  arm  in  a  sling  with  liberty  to  walk  about,  if  the  upper 
limb  is  concerned. 

The  joint  in  both  cases  protected  with  a  light  protective 
dressing  (cotton  wool  and  A  elpeau  bandages). 


Fig.   5i8.  —  ^^hite  swelling  of  right  knee  witli  marked  deviation, 
^ncl    ^'\  jjjx£    SWELLING   DISTINCTLY   FUNGOUS  OR  PAINFUL. 

Here,  in  the  town  as  in  the  hospital,  you  will  immediately 
apply  a  plaster  which  ivill  include  both  the  neighbouring  joints, 
so  as  to  ensure  more  certainly  the  immobility  of  the  affected  joint. 

3rd  W'hite  swelling  with  deviatio>"  (Gg.  5x8). 

The  indication  is  to  correct  the  deviation :  then  to  preserve 
the  correction  with  a  large  plaster. 

Be  prompted  by  Avhat  we  have  already  said  (v.  Hip  joint 
disease,  chap.  VI)  as  to  redressment  of  tuberculous  deviations. 

We  ought,  as  in  Hip  disease,  to  distinguish  between  two 
varieties  of  vicious  attitudes. 

i'*  :  Those  at  the  onset  or  during  the  acute  period  of  the 


OKI  iioiMM'Dic    lUEATMKM'   IN  <;ii:M:u.vr, 


^9' 


disease  \\lien   Llic    luhci'culosis  is  iiiosl  \iiuient,  ami  demands 
the  greatest  precautions. 

•>'"' :  The  vicious  atliliidcs  nearly  aiivay-''  pfiinless,  at  the  end 
or  at  llic  "  relapsing  "'  period,  vviicn  ihc  luhcrculosis  is  nearly 
extinct  or  even  quite  extinct.  Here  manipulations  of  a  vigo- 
rous kind  are  permissible. 


Fis. 


Fis;.  52i 


Fig.  519.  Fig.  520.  _  _ 

Fig.  510-522.  —  Correction  of  a  devialion  of  the  knee  by  successive  stages. 

a.  i^' METHOD.  —  Without  chloroform.  Redressment  by  stages. 

A  new  plaster  every  fortnight. 

One  gains  a  few  degrees  each  time,  Avithout  causing  pain, 
as  it  only  amounts  to  a  little  traction  or  a  little  pressure,  which 
can  be  effected  even  after  the  last  plastered  strip  has  been  applied. 

You  appeal  to  the  courage  of  reasonable  patients  who  will 
tell  you  freely  how  far  you  may  go  with  traction  without  arous- 
ing real  pain. 

One  attains  in  this  way,  in  the  space  of  two  or  three  months, 
surprising  corrections  and  even  complete  ones,  without  ma- 
king any  change  in  the  patient's  mode  of  life. 


492  WHITE    SWELLINGS     :     CORRECTION    OF    DEVIATION 

Figs.  619  to  52  2  represent  the  correction  by  stages,  made  by 
a  series  of  plaster  apparatus,  without  Chloroform. 

6.  2°'^  METHOD.   —  Correction  ivith  the  help  of  Chloroform. 

An  apparatus  every  i5  days,  in  the  way  we  have  just  described, 
is  however  too  much  under  certain  circumstances,  for  instance 
in  a  hospital,  for  a  very  busy  surgeon.  It  is  simpler,  for  example, 
little  as  one  may  be  familiar  with  anaesthesia,  to  give  a  few  drops 
of  chloroform  and  finish  at  one  or  two  sittings  at  the  most. 

Indeed,  by  the  help  of  chloroform,  one  accomplishes  almost 
immediately,  without  danger,  without  violence,  the  desired  correc- 
tion which  is  at  once  secured  by  the  application  of  a  plastered  appa- 
ratus. The  whole  affair  occupies  from  5  to  10  minutes  and  then 
three  months  of  rest  and  perfect  comfort  is  assured  for  the  patient. 

One  sitting  suffices  for  recent  vicious  deviations.  The  older 
deviations  require  generally  two  or  sometimes  three.  A  gene- 
ral rule,  Avhich  it  is  important  not  to  forget,  is  to  avoid  all 
useless  or  violent  manipulation. 

We  may  add  that  correction  is  always  attained  —  or  nearly 
always  —  by  simple  orthopoedic  manipulations,  by  a  simple 
redressment  without  having  recourse  to  an  osteotomy  or  even 
to  a  tenotomy, 

B.  —  TREATMENT  OF  THE  TUBERCULOUS  FOCUS. 

What  shall  we  do  to  cure  the  tuberculous  focus? 

A  treatment  consisting  of  rest  of  the  joint  and  its  immobi- 
lisation by  a  plaster  apparatus. 

Is  that  all.^ 

It  is  all  when  one  is  dealing  with  a  focus  in  Pott's  disease. 
But  if,  in  Pott's  disease  w^ithout  perceptible  abscess,  the  seat 
being  too  far  removed  from  the  lesions  prevents  us  doing  more, 
it  does  not  follow  that  our  attitude  will  be  the  same  in  articu- 
lations so  easily  accessible  as  the  knee,  the  foot,  the  shoulder, 
the  elbow  or  the  wrist ' . 

I.  From  this  point  of  view,  Hip  disease  stands  half  way  between  Pott's 
disease  and  white  swellings   of  the  different  joints.  The  hip  is  not  so  easily 


THE.VTMEM"   OF   Tilt:   TLHEUCLLOUS    Ff)CUS 


li[i6 


Here  we  may  choose  between  llic  lliico  '  Inlldw  iiii.--  Ircaliiienls 

i".  Mere  rest  in  a  plaster: 

2'"',  Removal  ol'  (lie  aiiicular  focus,  that  is  resection; 

S"',  Modifyiiig-  iulra-aiiicnl.u-  injections. 

Of  these  three  treatniOTils  whicli  is  the  best? 


Fie 


(see  descriptiou  of  Fig.  027). 


To  reply  to  this  question,  let  us  go  back  to  the  tubercu- 
lous type  of  lesion,  which  is  Cold  Abscess. 

In  fact,  is  not  white  swelling,  in  reality,  merely  a  cold 
abscess  of  the  articulation?     (fig.  oaS  to  027.) 

It  is  evident,  if  it  is  a  question  of  white  sAvelling  with  dis- 
charge.     But  it  is  also  true  of  Avhite  sAvelling  not  yet  softened  ; 

accessible;  nevcrtlieless  you  liave  seen  that  it  can  be  reached  by  following- 
the  method  gi\en  on  page  892. 

I.  The  method  of  de  Bier  in  white  swellings X>  I  do  not  know  this 
method  well  enough  to  be  able  to  express  a  definite  opinion. 

But  Avhat  I  can  sav  is  that,  in  some  cases  well  known  to  me  ^^here  it  has 
been  applied  for  tuberculous  arthritis,  it  has  produced  an  unmistakable 
aggravation.  Even  amputation  has  been  necessary  in  three  cases  treated  by 
it;  these  patients  -would  certainly  have  been  cured  by  the  treatment  we  advise. 


494         WHITE    SWELLINGS     :     INJECTIONS    THE    BEST    TREATMENT 

if  here  the  liquid  contents  of  a  cold  abscess  are  wanting,  on  the 
other  hand,  we  have  it's  virtual  cavity  and  especially  it's  cha- 
racteristic element,  the  only  essential  one  of  the  cold  abscess, 
namely,  the  proliferating  and  fungous  wall. 

It  follows  that  what  has  been  known  to  be  good  for  cold 
abscess  will  without  doubt  be  good  for  accessible   white  SAvel- 


Fig.  5a5. 


(see   description  of  Fig.  627). 


Fig-.  526. 


lings.  And,  if  there  is  one  thing  universally  admitted  in  cases 
of  cold  abscesses,  it  is  the  beneficient  revolution  which  has  taken 
place  in  their  treatment  since  one  punctures  and  injects  them  ; 
it  is  the  indisputable  superiority  of  punctures  and  injections 
over  pure  conservative  treatment  (rest  and  compression)  — 
which  is  too  uncertain  and  too  long  —  and  over  surgical 
operation  ivhich  rarely  cures,  often  aggravates  (by  leaving  a 
fistula)  and  always  mutilates^  (fig.  5 28). 

I.  If  it  is  true  when  one  operates  on  cold  abscess,  what  is  to  be  said  of 
the  mutilation  left  by  resections  in  childhood.^  They  inevitably  leave  a  lesion 
of  the  articular  cartilages,  whence  a  shortening  which  will  increase  later  on. 


THE    INJECTIONS    HAUOEN    Oft    DISSOLVE    THE    I'LNGOSI  IHCS       /|()5 

It  isexaclly  lliesaiiic  in  w  liilc  swellings,  where  tlie  Ircatrnent 
l)\  punclurcs  and  injeclions  is  infinitely  superior  to  ihe  two 
others;  it  is  cITicacious,  henign,  easy  to  use  everywhere  and 
relalivelv   rapid  ;    il    cures  in  a    few  months,  (S  to    12,  leaving 


Fig.  527.  —  Description  of  figures  oaS  to  627.  —  Analogy  of  suppnraled  while  swel- 
lings u'ilh  cold  abscess  :  the  figures  allow  us  to  realize  that  the  synovial  membrane 
(the  cul-de-sac  under  the  triceps)  may  become  separated  from  the  rest  of  the  arti- 
cular cavity  (pathological  adhesions  and  form  an  abscess.  The  abscess  is  cured, 
like  all  cold  abscesses,  by  punctures  and  injections.  The  articular  pocket  will  be 
cured  logically  by  the  same  method  (as  it  is  of  identical  nature  with  the  part 
which  has  been  separated  from  it), 

superior  orthopoedic  results  to  those  of  the  two  other  methods'. 
I  do  not  say  that   there  do  not  exist  some  cases  of  dry  or 

On  this  account  tvpical  resections  ought  to  be  condemned  -withovit  appeal,  in 
childhood. 

I.  Injections,  Ijv  advancing  the  date  of  cure,  allow  us  to  considerably 
shorten  tlie  period  of  severe  immobilisation  in  plaster;  and  thus  the  move- 
ments have  not  time  to  be  lost,  or,  if  lost,  they  may  return,  — whilst  surgeons 
who  do  not  make  injections  are  obliged  to  leave  the  plaster  for  three  long 
years,  whence  for  their  patients,  the  habitual  termination  by  ankylosis,  even 
after  mild  arthritis. 


496 


WHITE    SWELLINGS     :     INJECTIONS    THE    BEST    TREATMENT 


fungous  white  swellings  calling  for  either  conservative  treat- 
ment (recent  or  mild  arthritis  not  fungating,  the  child  not 
pressed  for  time  and  able  to  wait  for  years)  or  resection  (white 
swelling  of  knee  completely  and  easily  accessible  in  an  adult 
Avorking  man  to  whom  time  means  money).  But  apart  from 
these    special    exceptional    indications,   to    which    Ave    will 


Fig.   028.  —  An  example  of  the  poor  result  of  a  resection  of  the  knee   :   after  5    years, 
there  is  a  shortening  of  11  cm  fl)  as  well  as  a  pseudarthrosis. 


return,  the  treatment  by  injections  ought  to  be   the   regular 
treatment  of  tuberculous  arthritis. 

The  method  of  cure  of  white  SAvellings  with  effusion,  by 
the  method  of  injection,  is  easy  to  comprehend;  but  how  can 
injections  cure  a  dry  or  /ungating  white  swelling? 

In  this  way  :  By  making  the  injections  into  the  large 
articular  cavity  and  not  round  about  it,  Ave  reach  the  fungosi- 
ties  on  the  internal  surface  of  the  synovial  membrane  and  over 
the  osseous  surfaces,  that  is,  where  they  really  are. 

The   liquid,  placed  in  contact  Avith   the  fungosities,  modi- 


TFIE    INJECTIONS    IIAHUEN    OU    DISSOLVE    THE    l-llNr;OSlTIES.  '|(|- 

(ics  tlieiu  III   (wo  \\,i\s.  rilhci-  sclerosing  ihciii  or  Mjllcuiiig  lliein. 

Be  llic  Iraiisloniiiilioii  librous  or  licniilN  iiii;  llie  cure  will  be 
thus  proiiioled,  hastened,  assured;  if  I  here  is  sol  n  I  ion,  (li;il  is 
lo  say  intra-articular  cfTusioii  arliliciall\  brouglil  aboni,  one 
associates  the  punctures  with  the  injections,  as  in  the  case 
where  I'llnsion  existed  before. 

A^e  iiave  liquids  which  give  us  sclerosis  :  that  Avhich  gives 
llie  best  result  is  creosoted  oil  with  iodoform  (the  formula  is 
given  at  p.  no);  —  others  which  give  us  solution  of  the 
lungosities,  the  best  is  emulsion  of  camphorated  naphtol  in 
glycerine  (i/6  camphorated  naphtol  lo  5  6  glycerine;  see 
page  no,  the  dose  to  be  injected). 

I  call  those  which  produce  sclerosis,  injections  of  the  dry  type : 
when  they  bring  about  liquefaction  —  injections  of  the  liquid 
type.      In  a  general  way.  it  is  better  to  dissolve  than  to  sclerose. 

One  cures  better  and  more  certainly  by  dissolving  all  the 
tuberculous  products,  so  as  lo  be  able  to  expel  them  afterwards 
by  puncture,  than  by  transforming  them  in  silu  by  sclerosis. 
Bacteriology  allowed  us  to  foresee  this ;  clinical  Avork  has 
demonstrated  it.  One  Avill  make  then,  —  as  a  general  rule,  — 
injections  of  camphorated  naphtol  in  glycerine  rather  than 
injections  of  creosoted  oil  with  iodoform.  It  is  a  necessitv  in 
the  forms,  even  slightly  grave,  of  articular  tuberculosis. 

As  to  the  benign  forms,  the  injections  of  creosoted  oil 
with  iodoform  may  be  sufficient,  and,  as  they  cause,  as  one 
can  imagine,  less  inflammatory  reaction  than  the  other,  one 
may  give   injections   of  the   dry  type   in  all  town  children 

Avith  nervous  parents.  One  cures  three  fourtlis  of  the  cases  in 
this  Avay.  AA  hen  the  Avorst  comes  to  the  worst  in  those  Avho 
after  5  or  6  months  are  not  cured,  you  Avill  make  a  second 
series  of  injections,  this  time  of  the  liquid  type. 

To  recapitulate,  Avhen  white  swellings  are  drv  or  suppu- 
rating, the  treatment  by  injections,  if  it  is  avcU  done,  cures 
more  than  19  out  of  20  of  the  patients  in  the  space  of  from  8  to 

Calot.  —  IiicHspensable  orlliopedics.  02 


IxgS  TREA.TMEAT    OF    WHITE    SWELLOGS.    INJECTIONS 

12  months,  with,  very  often,  the  preservation  of  the  functions 
of  the  joints. 

This  preservation  of  mobility  is  obtained  especially  in  town 
patients  whom  Ave  are  able  to  follow  up  and  who  come  to  us 
before  the  period  of  osseous  destruction  has  set  in. 

STATISTICS 

To  give  you  an  idea  of  the  results  of  injections  in  tuberculous 
arthritis,  we  cannot  do  better  than  place  before  you  here  the  entire 
statistics  of  Avliite  swellings  treated  for  lo  years,  from^  January 
i8c)5  to  January  igoS,  inthe  hospital  Cazin  at  Berck,  where  all  white 
swellings  without  exception  are  treated  by  intra-articular  injections. 

The  number  of  these  white  SAvellings  amounted  to  3ii  (176  of 
the  knee,  77  of  the  ankle,  18  of  other  articulations  of  the  foot,  8  of 
shoulders,  i5  of  elbows,  17  of  the  wrist  or  other  articulations  of  the 
hand.) 

All  these  children  were  cured  within  a  year,  by  a  series  of  12  in- 
jections, except  7  of  them  Avho  were  cured  «fter  2  or  3  years  only, 
and  in  whom  a  new  series  of  injections  had  to  be  made  (even  a  third 
series  in  four  of  them).  There  existed  undoubtedly  several  inde- 
pendent foci  which  had  not  all  been  reached  by  the  fii'st  series  of 
injections. 

Not  one  death,  no  amputation,  nor  even  a  real  resection.  We 
have  not  performed  in  that  hospital,  for  the  last  ten  years,  more 
than  three  resections  of  the  knee  luith  a  purely  orthopcedic  object  in  view. 

These  children  have  been  cured,  as  we  said,  In  an  avei'age  of  8  or 
12  months,  namely,  3  months  for  the  Injections,  3  months  of  com- 
pression and  rest  after  the  injections,  and  finally,  from  4  to  6  months 
supervision,  still  at  rest,  to  be  assured  of  the  cure,  before  returning 
to  the  use  of  the  limb. 

From  the  point  of  vieAv  of  quality  of  result,  not  only  have  we 
obtained  limbs  of  normal  length,  position  and  strength,  but,  in  nine 
tenths  of  these  cases,  the  mobility  is  preserved,  but  not  however  in 
the  knee;  we  must  admit  that  in  the  hospitals  we  do  nothing  to 
preserve   suppleness  of  the  knee,  because   children  of  the  working 

I.  These  statistics  of  tlie  hospital  Cazin  are  the  most  striking  of  all 
those  I  am  able  to  quote  : 

i'^'.  Because  in  the  hospital  Cazin,  all  the  swellings  have  been  treated  by 
injection. 

2"'^   Because  the  method  has  been  followed  ^^ith  the  utmost  strictness. 


iNJECiioNs   ()i     wiiiii;   s\\  icij.ixis    Willi    l;ii  iJSioN  v.)',) 

class,  Willi  little  m  no  siipcrv  i^iun  ;il  tciw  aids,  liaNc  iiioic  iiccil  lor 
the  limo  Ijoiiii;  i>\  a  strong  liml>  wliicii  remains  well  cured,  than  a 
su|)j)lo  joint,  wliieli,  on  account  ol  it^  verv  suppleness,  is  o\|)0-;ed  lo 
sprains  and  relapses. 

It  ha[)|)eiis  also  verv  ol'lcn,  alter  a  vear  and  a  half  or  two  years 
ol  wjiitini;.  that  niobililv  in  the  knee  returns  of  its  own  accord. 

TliCII.YInH'J  or  THEATMENT  OF   WHITE  SWELLINGS 
BY  INTRA-ARTICILAR  INJECTIONS. 

'I.  —  White  swellings  with  effusion. 

Here  is  the  scheme  of  treatment  you  should  cany  out. 
\ou  apply  a  plaster,  ^\ilh  an  opening  for  the  injections.  After 
that  the  treatment  is  identical  v\ith  that  of  ordinary  cold 
abscess  (v.  Chap,  iii,  Trealinenl  of  suppurated  tuberculoses); 
the  same  liquids  in  the  same  doses,  are  injected  into  the  arti- 
cular cavity.  (You  will  find  in  the  second  part  of  this  chapter, 
the  place  for  injecting  each  articulations.) 

Thus  one  makes  from  7  to  8  punctures  with  as  many  injec- 
tions at  the  rate  of  one  every  6  or  8  days  —  which  extends 
over  about  two  months. 

After  that,  you  make  methodical  pressure  over  the  region 
with  squares  of  cotton  wool  introduced  through  the  opening 
in  the  plaster  and  supported  by  a  soft  bandage,  a  compression 
equal  to  that  required  for  a  gibbosity  (v.  Chap.  v).  You  leave 
the  limb  at  rest  in  the  plaster  apparatus  for  three  or  four 
months  longer.  The  examination  made  three  or  four  months 
later  shews  that  the  articulation  is  free  from  pain'. 

From  this  time,  the  joint  is  left  without  apparatus;  but  it 
still  requires  icst  for  several  months  (rest,  for  the  lower  limb 
on  a  frame  ;  in  a  sling  for  the  upper  limb).      It  is  during  these  few 

I.  If,  Aery  unusually,  three  or  four  months  after  the  injections,  pain  and 
fungosities  still  persist,  it  would  he  necessary  for  you  to  make  a  second,  and 
if  need  he,  a  third  scries  of  injections,  leaving  three  or  four  months  interval 
hetween  the  series.  This  necessity  for  the  second  series  of  injections  has 
occurred  to  us  3  times  in  a  hundred,  and  that  of  a  tliird  series  once  in  a 
hundred  onlv. 


OOO  ARTICULAR    OJECTIOS    O    DR^    WHITE    SWELLINGS 

months  of  rest  that  you  usually  see  the  movements  return 
spontaneously  by  the  sole  effect  of  the  joint  being  left  at  liberty 
and  without  any  direct  treatment ;  at  the  most  you  will  help 
it  by  a  few  baths  (  2  or  3  every  week). 

You  should  not  consider  the  child  cured  before  six  or  seven 
months  after  the  articular  extremities  have  been  freed  from 
pain  on  pressure. 

This  makes  for  the  entire  treatment,  on  an  average,  from 
8  to  12  months. 

TUBERCULOUS    HYDRARTHROSIS. 

If  instead  of  pus  in  the  joint  there  is  only  a  sero-fibrinous 
effusion  (do  not  forget  that  half  of  the  hydrarthroses  of  child- 
hood, in  particular  those  Avhich  continue  beyond  a  fcAV  weeks, 
are  of  tuberculous  nature),  one  will  carry  out  the  same  treat- 
ment as  for  distinctly  purulent  effusions,  with  this  difference, 
that  five  or  six  punctures  and  injections,  followed  by  two  punc- 
tures Avithout  injections,  suffice  generally  in  the  case  of  hydrar- 
throsis, to  ensure  the  cure. 

b.  —  Dry  white  swelling. 

One  applies  here  also  a  fenestrated  plaster  for  5  or  6  months. 
We  know  that  here  we  may  look  for  either  sclerosis,  or  solu- 
tion of  the  fungosities. 

Not  only  the  liquids,  but  also  the  number  of  sittings  and 
their  intervals  are  different  in  the  two  cases. 

i"*'  To  OBTAIN  SCLEROSIS,  onc  iujects  froiii  2  to  12  grammes, 
-according  to  the  age  of  the  subject  and  the  capacity  of  the 
joint,  of  creosoted  oil  with  iodoform,  and  one  will  make  only 
one  injection  weekly  (without  punctures,  seeing  there  is  nothing 
to  evacuate).      One  ceases  after  eight  or  ten  injections. 

2°''       To   EFFECT     THE    LIQUEFACTION     OF    THE     FUNGOSITIES,     OUC 

injects   the   mixture   of  naphtol    and    glycerine'    (v.    p.    i65), 
I.  Alone,  camphorated  naphtol  may  not  give  us  this  liquefaction 

with  certaintv.    —  Gaiacol,  or  thvmol  or  camphorated  salol  are  of  incompa- 


WHITE  s\vELLn(;s.  —  the  reactiox  puoduced  b^  injections    5oi 

givinp-  an  injccli'on  daily  unlil  llie  arliciilar  olTusimi  is  brou>ilil 
about. 

Thai  is  producctl  towards  the  IViuilli  das  (sdiiietinu's  on  llie 
tliii'd,  souielimcs  only  on  llie  lil'lh  or  sixth). 

As  soon  as  ihc  liquid  appears,  one  commences  willi  a  punc- 
ture and  finishes  with  an  injection,  loUow  ing  the  technique 
already  studied  for  white  swellings  with  effusion  existing  at  tlie 
onset. 

From  this  time,  spread  out  the  sittings;  one  only  every  five 
or  six  days,  which  gives  the  patient  a  rest,  the  daily  injections 
at  the  lieginning  being  fatiguing  to  him. 

The  treatment  following  the  injections  is  the  same  as  that 
given  above. 

The  reaction  caused  by  the  injections. 

Injections  ahvays  cause  a  certain  fatigue  and  a  certain 
reaction  ;  that  is  true  even  with  iodoform.  You  should  warn  the 
parents  of  this.  The  reaction  is  more  noticeable  with  injections 
of  naphtol,  especially  at  the  commencement,  where  they  have 
to  be  repeated  each  day  in  order  to  produce  the  articular  effusion. 

It  is  not  a  question  of  an  immediate  reaction,  which  with  our 
liquid  is  next  to  nothing,  but  of  the  desired  reaction,  the 
following  day  and  for  some  days  afterwards,  which  is  shown  by 
the  general  and  local  phenomena  of  an  acute  or  subacute  inflam- 
mation.     One    observes   a    certain    malaise,   loss   of   appetite, 

rably    less  value  (I  have  experimented  with,  them,  also,  for  a  long  time). 

But  camphorated  naphtol  needs  to  be  employed  with  considerable  cau- 
tion, that  is,  in  a  certain  dose  and  in  a  fixed  form. 

The  dose  is  from  6  to  3o  drops  for  each  injection  according  as  you  are 
treating  a  child  or  an  adult. 

The  form  in  which  it  should  be  used  :  never  alone,  alnays  intimately 
mixed  with  glycerine  in  the  proportion  of  one  gramme  of  camphorated 
naphtol  to  five  grammes  of  glycerine.  Refer  to  page  120  and  to  figure  107. 
Under  this  form  and  in  this  dose,  camphorated  naphtol  is  not  only 
inoffensive  but  is  just  as  efficacious  as  pure  camphorated  naphtol,  — 
that  is,  it  produces  on  the  fourth  or  fifth  dav  the  articular  effusion  sought  for. 

(See  the  thesis  of  Dr  H.  Saint-Beat,  igoS.) 


502  WHITE    SWELLINGS     :     THE    TREATMENT    TO    ADOPT 

sleeplessness,  at  the  same  time  slight  swelling,  pain  and  heat, 
and  occasionally  some  redness  of  the  neighbourhood  of  the  joint. 
The  temperature  reaches  38°,  oS'^b,  and  even  sometimes  Sg", 
with  the  doses  we  have  mentioned. 

If  then  after  the  first  or  second  injection,  the  temperature 
rises,  it  is  a  good  sign,  in  this  sense,  that  it  marks  the  very 
near  occurrence  of  effusion  in  the  joint. 

The  pain  and  other  symptoms  however  should  not  exceed  a 
certain  limit,  and  the  temperature  must  not  remain  at  say, 
39°,  beyond  a  few  days. 

Is  is  easy  besides,  to  moderate  the  reaction  when  loo 
violent ;  it  suffices  to  suspend  the  injections  for  one  or  several 
days,  or  even  to  inject  only  lialf  doses  of  the  liquid. 

Here  is  the  right  formula  :  provoke  sufficient  reaction  to 
obtain  the  articular  effusion,  but  not  enough  to  cause  excessive 
fatigue  to  the  patient.  One  keeps  it  at  the  desired  degree, 
about  38°,  by  increasing  or  diminishing  the  dose  of  liquid 
injected,  or  by  spreading  out  the  injections  or  lessening  the 
intervals  between  them. 

The  period  of  malaise  comes  to  an  end  when  the  effusion 
is  brougbt  about,  more  especially  as,  from  that  moment,  the 
object  being  gained,  one  can  widen  the  intervals  between  the 
sittings. 

c.  —  Injections  in  white  swellings  with  fistulae. 

The  rule  here  is  the  same  as  in  the  case  of  tuberculous 
fistulcB  in  general  (v.  p.  170  and  217). 

It  is  only  in  non-infected  fistulje  that  one  makes  modi- 
fying injections  (of  camphorated  naphtol  with  glycerine  or 
creosoted  oil  with  iodoform).  One  makes  one  injection  daily 
for  10  days  ;  then  pressure  and  rest  for  three  or  four  weeks. 
If  this  series  does  not  suffice  for  a  cure,  recommence  in  the 
manner  described  at  pages  173  and  180. 


IN     \\lliri£    SWI'I.LINCS    WirilOLT    EFFUSION  503 


CHOICE  OF  TREATMENT  ACCORDING  TO  THE 
CLINICAL  VARIETY   OF  WHITE  SWELLINGS 

r'  cvsii.  —  DRY  OR  FUNGATING  WHITE  SWELLINGS 
WITHOUT   EFFUSION) 

^^  c  said  dial  iiilia  articular  injeclious  are  our  usual  Ireat- 
ment  lor  ^^llite  s\\ tilings;  this  in  the  treatment  we  apply 
ahvays.and  from  the  beginning-,  in  hospital  practice.  In  town 
work  we  do  not  adopt  it,  neither  always  nor  I'rom  the  begin- 
ning, for  reasons  which  you  will  easily  understand.  There  are 
timorous  parents,  who  are  afraid,  instinctively,  Avithout  knowing 
why.      One  must  reckon  upon  their  opposition. 

As  moreover,  it  is  indisputable  that  a  tuberculous  arthritis 
has  many  chances  of  being  cured  without  injections,  in  a  good 
environment,  although  the  treatment  may  be  ilve  or  six  times 
longer,  it  is  true,  you  may  after  having  AA'arned  the  parents  of 
this  fact,  keep  to  the  purely  conservative  treatment,  without 
intra-articular  injections. 

Leave  the  child  at  rest,  as  in  the  first  case  of  hip-joint  disease, 
on  a  frame,  Avithout  a  plaster,  Avitha  simple  cotton  avooI  dress- 
ing. He  liA-es  by  the  sea  or  at  least  in  the  country  for  2  or 
3  years.      We  said  that  the  parents  are  in  no  hurry. 

As  long  as  the  joint  is  not  plastered,  there  is  no  fear  of 
anltylosis,  or  of  too  great  atrophy  of  the  limb. 

After  a  feAv  months  of  this  regime,  if  the  joint  has  become 
practically  painless  on  pressure,  if  there  are  no  more  fungosities, 
if  the  position  is  still  correct,  Ave  may  expect  a  cure  and  Ave 
Avill  continue  the  same  treatment. 

But  if  the  Avhite  SAvelling  is  stationary  and,  still  more,  if 
it  has  progressed,  if  fungosities,  pains,  or  a  deviation  haAC 
appeared,  there  is  proof  that  a  cure  aaIII  not  be  obtained  Avithout 
injections,  or,  at  least,  that  it  Avill  not  happen  for  long  years. 
The  duty  of  the  surgeon  is  then  to  insist  again,  AA^th  the 
parents,    so    that    they   agree  to    alloAv    the   use   of  modifying 


5o4 


WHITE    SWELLOGS. 


BEISIGN    A>D    RECENT 


injections.  Tell  them  that  the  injections  Avill  :  V,  ensure  and 
hasten  the  cure,  2"'\  yield  a  better  cure  than  the  conservative 
treatment  would  do  in  a  similar  case. 

This  point  settled,  here  is,  recapitulated  in  a  few  words,  the 
course  to  be  folloAved  in  cases  of  dry  or  fun  gating  AAhite  swellings. 

The  three  following  clinical  varieties  must  be  distinouished : 


Fig.  029.  —  Diseased  knee  joint.  — 
Swelling  of  the  joint.  —  The  pa- 
tella appears  projected  in  front. 


Fig.  53o.  —  Healthy  knee  joint  seen 
on  its  external  surface. 


a      White  swellings  benign  and  recent. 

Practically  no  fungosities,  no  deviation,  no  spontaneous 
pains  (fig.  629,  53o). 

]}  hen  treating  a  town  patient.  —  If  the  parents  are  unwill- 
ing to  have  the  injections  given,  place  the  joint  at  rest,  with 
or  without  plaster,  and  wait. 

If  you  have  entire  liberty  of  action,  make,  from  the 
outset,  injections  of  creosoted  oil  with  iodoform  after  having 
put  on  a  plaster  to  be  kept  on  as  long  as  the  injections  are  made, 
and  for  a  few  weeks  afterwards. 


AVIIITK    8\\  KM.INCiS,     ILWGATING    AM)    (iUAVE  5o3 

ir  von  see.  after  three  or  four  months  of  waitinf:,  that  this 
is  not  sufficient,  if  funirosilies  or  pain  on  pressure  persist, 
make  injections  of  campliorated  naphtol. 

I1i  hen  YOU  are  treafini/  a  hospital  patient,  injccl  camphorated 
naphtol  with  glycerine  from  the  outset  (after  the  application 
of  a  plaster). 

b.  Fungating  and  grave  white  swellings  with  or 
Avithout  devialions,  and 

c.  Old  and  painful  white  swellings,  already  several 
years  old  and  nii.slahen  far  chronic  rheumatism  : 

For  these]  tAvo  varieties  (6.  and  c);  from  the  arrival  of  the 
patient,  plaster  apparatus,  after  correction  of  vicious  position, 
if  he  has  one;  then,  the  next  day  or  the  day  afterAvards, 
injections  of  camphorated  naphtol. 

In  these  old  white  sAvellings,  consisting  prohablyof  multiple 
independent  foci,  one  must  make  similar  and  simultaneous 
injections  at  e\ery  point  where  a  tuberculous  focus  is  supposed 
to  exist,  and  make,  if  need  be,  a  second  and  a  third  series,  at 
three  or  four  months  interval  the  one  from  the  other. 

It  must  be  unterstood,  however,  that  in  dealing  with  an 
adidt  Avorkman,  always  in  a  great  hurry,  and  if  you  are  a  sur- 
geon and  Aery  certain  of  your  asepsis,  you  may  at  the  outset, 
suggest  resection  ',  because  it  Avould  be  a  saAing  of  time  to  the 
patient. 

If  you  are  not  a  surgeon,  you  may,  exen  in  this  case,  keep 
to  the  treatment  by  injections  of  the  liquid  type,  repeated  if 
necessary.  They  Avill  succeed  in  the  end,  nine  times  out  of 
ten,  and  the  orthopoedic  cure  so  often  obtained  will  be  at  least 
equal  to  that  Avhich  resection  aaouH  give,  —  at  the  cost  of  a 
litUe  patience  and  time,  it  is  true  (a  year  or  a  year  and  a  half 
instead  of  from  three  to  iixe  months).  Avithmit  any  risk  to  the 
patient;    this    cannot    be   said   of   resection.   Avhich   very    often 

I.  Or  better,  after  a  series  of  injections  (5  or  6,  made  in  the  space  of  a 
month),  which  will  much  attenuate  the  virulence  of  the  tuberculosis  and 
Avill  ensure  union  bv  first  intention. 


5o6  WHITE    SWELL1?«GS    WITH    EFFUSION 

leaves  fistuloe,  in  Avhich  case  the  situation  would  be  very  noti- 
ceably aggravated  by  operation. 

2-1  CASE.  —  WHITE  SWELLINGS  WITH   EFFUSION, 

PURULENT  OR  SERO-FIBRINOUS 

(TUBERCULOUS  HYDRARTHROSIS)  (fig.  53i). 

Always  and  everyAvhere,  in  town  or  in  hospital,  in  adult  or 
in  child,  there  is  only  one  rational  treatment  :  plaster, 
punctures  and  injections,  either  with  creosoted  oil  and  iodoform, 
or,  with  camphorated  naphtol  and  glycerine  (v.  p.   ii5). 

3d  CASE.  —  WHITE  SWELLINGS  WITH  FISTUL>E 

Read  again  Avhat  we  have  said  (chap.  VI)  on  fistulaj  in 
hip-joint  disease. 

The  treatment  differs  according  as  the  fistulse  are  infected 
or  not  (v.  for  this  difference,  p.  225). 

In  non-infected  fistulfe,  you  will  make  injections  and  the 
cure  will  be  obtained,  generally,  in  a  fcAV  months. 

In  infected  fistulse,  no  modifying  injections  of  iodoform 
or  of  camphorated  naphtol  are  made. 

At  the  most  you  will  try  syringing  with  solution  of  per- 
manganate of  potash  or  with  very  Aveak  carbolised  Avater. 

You  must  confine  yourself  to  a  discreet  therapeusis,  simple 
asepsis,  and  good  general  treatment  :  you  Avill  need  abundant 
patience,  for  the  cure  requires  i,  2  or  3  years.  But  at  last 
the  cure  is  obtained,  at  least  in  an  ideal  environment  such  as 
that  of  Berck. 

So  much  for  the  case  Avhere  there  is  no  fever,  or  not  much. 

But  it  is  not  sufficient  Avhere  there  is  fever. 

You  Avill  have  to  drain,  to  overcome  it. 

If  the  fever  persist  in  spite  of  drainage,  in  spite  of  arthro- 
tomy  (that  is,  an  extensive  opening  of  the  articular  cavity  and 
removal  of  any  squestra  you  may  find)  and,  in  spite  of  resec- 
tion;  or  again,  if  the  viscera,  liver  or  kidneys,   shoAV  the  first 


lltlvVI  \II.M'    OF     FISTULOIS     W  III  I  i:     S\\  KM.INCiS 


;)()7 


si^ns    of  dof^oiuMarKiii.  owinp'  In   iiifcclion   cxlcncling   IVom    the 

i)crii)heral    foi-iis;   or   if  llu'  [laliciil    is  raclioclic  and    ihc  lungs 

are  begiiinini;  lo  he  liibciciiloscd,  resign  Nniiisclf  to  sacrificing 

the  hnih.       This  is  a  last  resource  which  we  do  nol  have  in  hip 

join!    (Hsoasc.      liuL   you    must   not 

have   recourse  to  it  except  as  a  last 

extremitN.    thai     is,    \\hcn    you  are 

morally  certain   that  the  life  of  the 

patient  is  in  immediate  damjer  and 

can  not  be  saved  irilhoiil  aniputation 

of  the  limb^ . 

Neverlheless.  amputation  issomc- 
times  proposed  outside  the  prece- 
ding indications,  and  in  the  case  of  a 
working  man  whom  the  necessities 
of  life  oblige  to  return  to  the  unwhole- 
some surroundings  of  a  large  town. 

His  fistula,  more  or  less  infected, 
A\  ilhout  for  the  present  endangering 
his  life,  has  not,  nevertheless,  much 
chance  of  being  cured,  and  causes 
far  too  much  risk  of  bringing  about 
in  the  long  run  a  generalisation  of 
the  tuberculosis.  It  would  be  better 
then  to  amputate. 

If  the  lower  limb  is  in  question, 
one  would  not  even  attempt,  as  a 
preliminary,  a  very  large  resection, 
which  would  only  cure  the  patient 
with  a  limb  so  shortened  that  it  would  be  of  less  use  to  him 
than  a  good  stump  '. 


Fig'.  53 1  —  AVhite  swelling  with 
effusion.  —  The  knee  is  very 
swollen ;  no  osseous  reliefs  are 
apparent ;  fluctuation  quite  dis- 
tinct. 


I.  And  on  the  otiier  hand,  lo  be  morally  certain  that  amputation  aaIII 
save  him,  that  is,  that  the  intervention  is  not  too  late. 

■3.  At  Berck,  I  do  not  perform,  on  an  average,  one  amputation  a  year, 
amongst    manv    scores  of   fistulous  Avhite    swellings    in    children    or    adults, 


5o8       TREATMENT    OF    ANKYLOSIS    FOLLOWING    WHITE    SWELLING 

4".  CASE.    —  WHITE  SWELLINGS   CURED   OR  APPARENTLY 
CURED  WITH  ANKYLOSIS 

Your  course,  in  the  presence  of  an  ankylosis,  will  differ 
according  as  it  is  accompanied  AAath  a  deviation  or  not. 

Leave  it  alone  if  there  is  no  deviation,  or  rather  you 
Avill  only  deal  with  the  ankylosis  by  very  slight  methods  : 
very  gentle  massages;  the  Baths  of  Bareges,  Bourbonne,  Aix, 
Dax,  Salies,  or  Argeles-Gazost '. 

On  the  other  hand,  if  there  is  a  deviation  and  the  func- 
tions of  the  limb  are  seriously  affected,  you  must  correct  it. 

No  surgical  operation  for  this,  not  even  a  tenotomy ;  but 
correction  by  simple  orthopoedic  movements  with  or  without 
chloroform;  by  stages,  one  correction  every  five  days,  each 
partial  correction  being  followed  by  the  application  of  a  plas- 
ter;  3  or  4  sittings  suffice.  By  this  method  you  will  succeed, 
because  the  ankylosis  is  hardly  ever  really  complete,  that  is, 
osseous. 

Never,  or  scarcely  ever,  will  you  need  to  perform  osteo- 
tomy", nor  orthopoedic  resection. 

As  for  me,  I  do  not  perform  one  per  year  on  an  average, 
although  I  redress  annually  a  hundred  ankyloses  folloAving 
white  swellings.  As  soon  as  you  have  transformed  the  ankylosis 
with  deviation  into  an  ankylosis  in  good  position,  you  will 
leave  it  alone  and  do  nothing  to  mobilise  it^ 

whom  I  treat  altogether;  but  tlie  patients  are  not  all  able  to  come  to  Berck, 
nor  wait  two  years  for  their  cure.  This  means  that  you  maybe  obliged, 
more  often  than  the  Doctors  of  Berck,  to  perform  the  painful  task  of  ampu- 
tating. 

1.  See  "  Argeles-Gazost  from  a  medical  point  of  view  "  by  my  old  assis- 
tant, D'  Bergugnat. 

2.  Osteotomy,  should  it  ever  seem  indispensable  to  you,  is  easily  and 
simply  performed.  See  chap.  x.  as  to  how  it  is  done  at  the  knee,  the  supra- 
condylar osteotomy  of  Mac  Ewen. 

3.  Doubtless,  it  is  very  different  for  a  specialist  quite  familiar  with 
these  therapeutics,  and  practising  in  an  orthopoedic  institution  which  is  fur- 
nished with  all  the   installations  desirable  fbalneo-therapy,    electro-therapy. 


DO    ?iOT     Moltll.lSi:    A\     ANkM.o-IS     FOLLOW  ING     W  IIITF:    S\\  KLLING      O09 

I  lii'ir  WDiild  l)('  [ou  IcNV  I'liaiUH's  ol  ic^li  iiinjj  im  iNcinciit 
and  liio  iiimli  risk  of  losing  (he  good  posilioii  of  llic  lindj  in 
endeavouring  lo  tlo  litis. 

The  ciiic  of  while  swelhngis  achieved  in  good  position.  The 
patient  \\ill   ihin   have  a  very  useful  lind). 

Be  salislii'd  wllh  lhi<  \(i\  hduouraiilr  rc^idl.  and  lake  care 
not  lo  spoil  it,  Iroin  I  he  I'unclional  point  of  view,  or  even  lo 
re-awaken  the  disease  in  Uung  lo  restore  tlie  articular  supple- 
ness which  has  heen  lost. 

If  I  endeavour  to  warn  you,  in  the  course  of  ihis  book,  of 
all  that  you  can  and  ought  to  do,  I  endeavour  also  to  point  out 
that  Avhich  you  cannot,  that  which  you  ought  not  dare  to  do. 


mccano-therapy,  etc.).  Here  one  can  have  recourse  not  only  to  massaire, 
but,  in  certain  well  understood  cases,  to  the  mobilisation,  discreet  and  pru- 
dent, active  or  passive,  of  stiffened  joints. 

l^assive  movements  are  sometimes  effected  bv  mathematically  regulated 
machines,  such  as  our  arthromoteur,  or  by  the  hands  of  the  doctor.  Occa- 
sionally even,  in  certain  infinitely  rare  cases,  one  practises  forced  mobilisa- 
tion of  the  ankylosis  under  chloroform,  to  bring  back  movements;  after 
this  the  limb  is  immobilised  for  i  or  2  weeks;  then  the  mobility  thus  educed 
from  the  joint  is  developped  by  massage  and  passive  manoeuvres. 

But  these  treatments  are  so  special  in  nature,  their  results  call  for  so 
much  time  and  care,  they  have  so  few  chances  of  success  in  the  hands  of 
the  majority  of  practitioners,  that  I  do  not  hesitate  to  formally  advise  you 
not  to  attempt  them. 


II 


SECOND    PART   OF   CHAPTER   VII,  OR  THE 

TREATMENT  OF    EACH   WHITE 

SWELLING    IN    PARTICULAR 

What  AA"e  have  said  in  the  first  part  of  this  chajjter  is  apph- 
cable  to  all  the  Avhite  swelUngs. 

AVe  must  noAV  pass  in  review  the  wliite  swelhngs  of  diffe- 
rent joints,  in  order  to  point  out  the  pecuHarities  Avhich  each 
of  them  presents. 

WHITE   SWELLINGS  OF   THE  KNEE  ' 

White  SAvelhng  of  the  knee  is  the  most  frequent  of  them 
all.  It  is  the  type  of  the  Avhite  swelling,  that  which  Ave  have 
especially  in  view  in  our  clinical  and  general  therapeutic  study 
of  Avhite  swellings.     We  will  add  only  a  few  things  here. 

1st.      From  the  point  of  view  of  Diagnosis  (Tig.  532  to  "boi)). 

a)  I  have  no  need  to  teach  you  how  to  find,  by  looking 
for  the  patellar  "  choc  ".  the  existence  of  effusion. 

h)  It  is  here  especially  that  we  have  to  distinguish  simple 
liydrarthrosis  from  tuberculous  hydrarthrosis. 

If  the  hydrarthrosis  continues  for  more  that  6  or  8  weeks, 
in  spite  of  puncture  and  pressure,  it  is,  nearly  ahvays,  symp- 
tomatic of  a  tuberculous  arthritis. 

In  the  presence  of  a  double  liydrarthrosis,  Avithout  limita- 
tion of  movements,   one  ought  to  think  of  syphilis,  if  there  are 

I.   See  the  tliesis  of  :  D"'  Dulac,  1898;  D"^  Cli.  Benoit.  1906;  D'  Gresson, 
of  St-Petersbourg,  iqo5. 


WllllE    SWELLING    OF     1111.    KNLL.    l>LVG>OSlS.    I'llOGNOSIS       5ll 

aii\   aiiteccilenls.  and  even    wlicii    in   (Imiht,    Inllow    llic  s|)('(ili<-, 
licatiiicul   (\.   chap,   xvi,  Syphilis  of  llic  sht'lelnii). 

c)      In  ailolcscciits  and  in   adults,  an   al•tlll■ili■^   of   IIk'  knee. 


i'ig.  532    —  To  search  for  fangosities.  —  Schema  of  the  anatomy  of  the  synovial 
membrane,  which  is  seen  tinted  in  grey  behind  the  patella. 


which  has  appeared  wilhout  apparent  cause,  is  probably  due  to 
a  blennorrJiagia  and  one  ought  ahvays  to  examine  the  patient 
'with  this  in  view. 

2°''.     .4^  to  Prognosis. 

Refer  to  what  we  said  at  page  489  on  this  subject. 


5l2        THE    FUNCTIONAL    RESULT    IN    WHITE    SWELLING    OF    THE    KNEE 


One  can  restore  a  leg  straight,  strong,  and  useful,  to  these 
patients,  but  not  always  the  movements. 

One  must  note  that  this  mobility  is  much  more  difficult  to 
obtain  in  the  knee  than  elsewhere. 

With  the  best  treatment 
Ave  succeed  in  scarcely  more 
than  half  the  cases  (in  the 
knee). 

Moreover,  the  mobility 
is  not  always  desirable  for 
the  patient,  as  you  Avill  see. 

The  functional  result  to  be 
looked  for  in  the  knee. 

P*.  Ill  children  and  in 
adidts  of  the  upper  classes. 

1tou  will  look  for  cure 
with  preservation  of  move- 
ment only  when  the  white 
swelling  is  benign  and  re- 
cent, and  when  the  position 
and  suppleness  are  normal 
or  nearly  normal. 
J  h    ii     I    t      li   i'\^  '^fiW'fMi\  '^^'-'^^  ^^^^^  succeed  then, 

I  k  A    ihffll  lilll  llllllil  Hm\  i'^  preserving  the  mobility, 

in  0/4  01  tlie  cases  m 
children  and  in  half  of  the 
cases  in  adults. 

This  is  how  )ou  will 
do  it  :  you  will  not  leave  the  plaster  on  for  more  than  4  or  5 
months,  namely,  two  months  Avhile  the  injections  are  being 
used,  and  for  2  or  3  months  after  that;  afterwards  leave  the  knee 
free,  with  a  simple  bandage  of  Velpeau  crepe,  but  still  at  rest 
in  the  horizontal  position  for  5  or  6  months;  that  makes  lo  to 
12  months  for  the  total  duration  of  treatment. 


Fig.  533.  —  The  same  seen  in  front  (always 
tinted  grey)  exposed  to  view  on  each  side  of 
the  patella. 


STIFFNESS    IN     Wlim:    SWKI.MNC    OF     llli;    KNFE 


5i3 


Tlieii  ycm  iiia\  allow  [jalieiils  to  slaiul  on  their  feet;  let 
iheni  -walk  with  a  larj^e  ap[)aratiis  in  celluloid  rcacliii)y  from 
llic  pelvis  to  llic  foot,  but  jointed  at  the  hip  and  ankle.  The 
apparatus  is  removed  during  the  intervals  belwccn  the  walking 
exercises,  and  all  night.      Remove  it  entirely  after  a  year's  use. 


Fig.  53'|.  —  Searcliing  for  Jluclualion.  — Make  tlie  lluitl  move  from  tiie  peripliery  to 
the  centre  by  pressing  over  the  synovial  sac,  above  and  below  the  patella,  with  the 
two  hands  in  the  form  of  a  horse-shoe    i''  step). 

\ou  look  for  cure  by  ankylosis,  on    the  contrary,   in  all 
cases  of  rather  old  Avhite  SAvellings  (dating  back  a  year  or  more) 


Fig.  jo3.  —  2'"'  step;  Keeping  up  the  pressure,  one  brings  the  hands  together  and 
with  one  of  the  index  fingers,  one  taps  on  the  patella  as  one  touches  the  piano:  in 
this  way  one  obtains  the  patellar  «  choc   ».   the  sign  of  the  presence  of  fluid. 

and  of  grave  character,  with  a  markedly  vicious  position  (flexion 

of  more  than  20°,  Avith  subluxation  outwards  and  backwards). 

Lock  for  it  also  in  all  cases  of  the  first  group  where  the'move- 

Calot.   —  Indispensable  orthopedics.  33 


5i4 


SOME    RADIOGRAMS    OF    WHITE    SWELLINGS 


ments,  having  been  preserved  or  recovered,  the  position  becomes 
bad  as  soon  as  the  patient  is  left  without  the  apparatus  or  when 


Pig    3ih  Fig.   537.  Ijt,    538 

Fig  536.  —  The  fiist  radiogram  to  the  left  of  the  reaclei  (fig.  53b j  is  that  of  the 
affected  side.  The  second  (fig.  oSy)  that  of  ihe  sound  side.  —  A  child  of  six  and  a 
half  years  —  Tuberculous  arthritis  of  four  months  standing.  General  tint  brighter, 
the  interline  more  narrow,  epiphysial  parts  more  developed  over  the  affected  knee. 
Fig,  538.  —  White  SAvelling  of  the  knee,  one  and  a  half  years  standing  (a  child  of 
seven  years).  —  The  interline  is  blurred;  the  diaphyso  epiphysial  angle  of  the 
tibia  presents  an  anterior  concavity. 


Fig.    539     —  Osleo-sarcoma  of  shoulder  (had    been   mistaken    for    a  Avhite    spelling). 


AMirn:  swi^llincj  of  tiii:   knee 


5i5 


Fig.  5^0.  —   Bonnets  apparatus  for    mobilising  the  knee. 


Fig.  54 1.  —  View  of  the  knee  part  of  the  apparatus  fig.  5^0. 


5l6       FU]\CTIO>'AL    RESULT    IX    AVHITE    S^YELLIXG    OF    THE    RXEE 

he  is  noticeably  lame  or  incapable  of  taking  a  lono-  Avalk. 
To  obtain  ankylosis,  he  is  made  to  Avear  knee-caps  of  plas- 
ter or  of  celluloid  until  the  knee,  "  let  loose  ",  for  a  few  days, 
keeps  straight  of  its  own  accord,  -which  sometimes  requires 
three   or  four  years  or  even  more.     When  the  knee  has   been 


Fig.   542.  —  A  more  simple  arrangement  for  mobilisation  of  the  knee. 

cured  for  at  least  a  year,  and  remains  in  good  position,  you  may 
leave  off  the  apparatus. 

The  knee  will  be  stiff  but  the  result  remains  however,  very 
satisfactory. 


Especially  beware    of   all  forcible   mobilisation  with  or 
Avithout  chloroform. 

These  forcible  mobilisations  are  the  causes,  as  we  have  said, 


will  IE  s\\i:i.Li\(.  OF  THE  km:e  5 17 

of  lar  loo  iuan\  tlisa|i[)i)iii(iiiciils  to  [jracliliuiicrs  wliu  arc  not 
specialists. 

Conliiic  \ourscir  lo  massage,  to  daily  baths,  saline  or  sulphu- 
rous, to  some  attempts  at  flexion  made  by  the  patient  in  the 
bath,  by  the  action  of  tiic  muscles  of  the  leg  alone. 

At  the  most,  and  quite  exceptionally,  and  only  a  year  after 
the  cure  is  unmistakeable,  A\ould  you  alloAV  very  gentle,  very 
cautious  exercises,  made  Avith  graduated  machines  moved  by 
the  patient  himself,  progressing  by  only  a  degree  or  a  degree 
and  a  lialf  every  day  (fig.  55o  and  542). 

And  you  must  always  be  prepared  to  stop  these  exercises 
at  the  first  sign  of  inflammation,  and  in  that  case,  to  abandon 
altogether  your  attempt  at  obtaining  articular  mobility. 

Besides,  it  very  often  happens  (in  more  than  a  third  ot 
the  cases),  that  movement  returns  spontaneously,  without 
any  special  treatment,  a  year  or  two  after  the  cure  of  a  tuber- 
culous arthritis.  —  Everyone  has  seen  examples  of  this,  espe- 
cially in  very  young  subjects. 

II.  —  Children  and  adults  in  hospital  or  of  the  working  class. 
—  After  the  preceding  considerations,  need  Ave  especially 
mention  that,  one  ought  not,  in  patients  of  this  category,  to 
look  for  a  cure  with  preservation  of  movement? 

Cure  them  Avith  the  knee  stiff.  A'N'hen  the  knee  has  remained 
in  a  good  position,  a  year  and  a  half  or  two  years  after  the  cure  has 
been  accomplished,  free  the  patient  from  aU  kind  of  apparatus. 

We  have  observed  in  our  hospital  chidren  as  well  as  in 
private  cases,  but  a  little  less  frequently,  that  mobility  has 
returned  in  due  course,  spontaneously. 

S--'^  From  the  point  of  view  of  THE  CLINICAL  ASPECT 
and  of  the  THERAPEUTIC  INDICATIONS. 

Vse  will  add  jus  I  one  Avord  to  Avhat  has  been  already  said 
concerning  deviations. 

A  lateral  deviation   (genu  valgum  or  subluxation  of  the 

I.   See  my  Traile  des  tamears  blanches,  Masson,  p.  220. 


5i8 


PARTICULARS    OF    ITS    TREATMENT 


tibia  outwards  and  backwards)  nearly  always  accompanies 
direct  flexion  of  the  tibia  (fig-.  543,  544)-  —  As  to  complete 
luxation  of  the  tibia  backwards  (fig.  545,  546),  into  the  popli- 
teal space,  you  will  doubtless  never  see  it;  I  have  seen  it  only 
twice  in  seventeen  years. 


Fig.  543. —  Anotlier  type  of  white  swelling.       Fig.  54-'|. —  W.  S\v.  with  genu  valgum. 

But  we  must  draw  your  attention  to  the  lengthening  of 
the  affected  leg  Avhich  is  often  produced  in  these  Avhite  swel- 
lings, and  is  due  to  the  greater  fertility  of  the  articular  carti- 
lages of  the  affected  side  than  of  the  sound  one. 

This  fertility  is  rarely  ever  stimulated,  and  lengthening  only 
exists  in  benign  arthritis;  it  is  often  compromised  on  the  contra- 
ry, in  severe  wh  ite  swelling,  whence  here  there  is  shortening. 


wimi;   >\\i;Li.iNG   of  the   k.M;i: 


y  Kj 


Li'iiylhi'iiiny,  wIktc  il  exists,  is  oiii\  lciiii)orar\  ;  allor  one, 
two  or  Ihree  years,  (he  caiiila^yo  of  llie  sound  side  ovcrlakcs  ihe 
other  and   llie  ei|ualil\    ni'  the  two  Irixs  is   re-eslahlislicd. 


Fig-.    5/|0.  —  Lucieii  L...  of  Pai-is.  —  Complete  luxaliun  of  tlie  lijjia  into  llie  iiuplileal 
space,  existing  about  live  years  (radiogram). 

In  the  meanlime,  for  walking,  you  would  have  to  provide 
a  thick  sole  for  the  sound  limb. 


l^ig-  5^6.  —  The  fame,  after  reduction,  without  surgicat  interference.  —  The  reduc- 
tion was  made  November  iS""  igo5  (under  chloroform).  —  With  the  appa- 
ratus shewn  in  figures  867  and  868,  we  made  traction  on  the  leg  up  to  70  kilo- 
grammes for  1 5  minutes,  which  pulled  down  the  articular  surface  of  the  tibia  ft) 
the  level  of  the  surface  of  the  femur.  —  Then,  by  pressure  downwards  on  the 
femur  and  upwards  on  the  tibia  we  brought  the  two  surfaces  into  contact.  — 
Afterwards,  a  large  plaster  ifrom  the  umbilicus  to  the  toes\  In  the  plaster,  we 
made,  the  next  day,  two  openings;  one  in  front,  opposite  the  condvles,  the  other 
behind,  opposite  the  tibial  tuberosities,  and  by  these  openings  a  double  cotton-wool 
compression  (as  in  our  apparatus  for  Pott's  disease^  to  maintain  and  further  per- 
fect the  reduction.  Five  months  later  the  reduction  persisted. 

4'"'  From  the  point  of  view  0/ TREATMENT. 

^^  e  will  add  to  what  has  been  s-Aid,  in  the  Generalities,  a  few 
words  on  the  apparatus,  the  correction  of  vicious  positions,  the 
technique  of  injections  and  the  surgical  operations  on  the  knee. 


020 


APPARATUS    IN    WHITE    SWELLING    OF    THE    KNEE 


A. —  The  Apparatus. 

To  immobilise  the  knee  satisfactorily,  if  it  be  a  question  of 
preventing  a  deviation  or  maintaining  a  correction,  it  is  neces- 


Fig.  547.  Fig.  5/,8.  Fig.  549. 

Fig.  5/17.  —  The  small  knee  piece  very  often  made.      Much  too  short  and  too  loose ; 

the  soft  tissues  can  be  pressed  in   hy  the  edges  of  the  knee  piece   and  deviation  is 

produced  at  will. 
Fig.  548.  —  A  longer  knee  piece;  but  still  defective,  for  the  same  reason,  but  in  a 

lesser  degree. 
Fig.  5/19.   —  The   perfect  method   of  immobilising  the   knee,   —   Our    large  plaster, 

which  takes  in  not  only  the  knee,  but  also  the  two  neighbouring  joints. 

sary  to  make  a  large  plaster  which  includes   the  two  adjacent 
articulations  (hip  and  ankle). 

It  is  sufficient  to  cast  one's  eyes  on  the  diagrams  above,  to 
see  how  the  classical  "  knee-piece  "  is  incapable  of  immobilis- 
ing the  two  articular  levers,  in  cases  ever  so  little  intractable. 
The  plaster,   then,   must  reach  from  the  umbilicus  to  the  toes 


i)i:i  (lUMi  I  ii>   IN    wiiiii:  sw  1:1.1. i\(;   of  riir;  knei; 


aiul  \\\\\  be  in  cvcrv  \\;i\  llic  same  as  llic  larfrc  a[)paralus  for 
hip-joiiil  disease  (lly.  o/j-  lo  ')^\\)). 

^^  hen  laif-'e  orlliopa?.dic  apparatus  (celluloiti  or  leallier)  arc 
used,  lliev  niav  be  ailirnlalod  ;i(  ibc  bip  ;ind  ihe  fool,  leaving 
the  knee  fixed. 

It  is  onlN  when  the  lendenc\  to  deviation  no  lon^^er  exists 
that  one  can  dispense  Avitb  taking  in  the  luo  neighbouring 
joints  (fig.  55o).  A  medium  plaster  is  then  used,  reaching 
from  the  ischium  to  the  toes,  and  immobiUsing  only  one  of  the 


Fig.  55o.  - —  The  medium  apparatus  reaching  from  the  ischium  to  the  toes. 

adjacent  articulations,  or,  even  simply  the  ordinary  knee-piece 
■which  leaves  them  both  free. 

Finally,  let  us  say  that,  to  immobilise  the  knee,  circular 
plasters  are  better  fitting  and  more  accurate  than  splints,  and 
ought,  in  consequence,  to  be  preferred. 

The  large  anterior  opening  of  the  circular  plaster  allows  of 
the  examination  of  the  knee  and  of  the  articular  injections  being 
made  without  difficulty. 

B.  —  The  Correction  of  Vicious  Position  of  the  Knee  Joint. 

a.  Continuous  extension  may  be  of  service  in  private  cases 
Avhere  the  parents  dislike  plaster  (fig.  552,  553). 

When  it  is  a  question  of  deviation  at  the  onset,  and  you 
are  able  to  attend  to  it  Aery  closely,  you  will  in  this  Avay  obtain 
the  correction  —  Avith  a  continuous  extension  arranged  by  you 
and  looked  to  every  Aveek. 

But  it  is  simpler  to  redress  than  to  put  on  a  plaster. 


522    DEVIATIONS   OF   THE    RNEE, 


THE    METHOD  OF  CORRECTING   TIIEM 


h.  Forcible  redressment  of  the  knee.     We  have  only  a  little 

to  add   to  Avhat  has  been  said  in 
the  Generalities. 

Take  care  to  make  more  trac- 
tion on  the  foot  than  direct  pres- 
sure on  the  knee  (fig.  55/1),  which 
would  lead  to  bruising  or  fracture 
of  the  articular  extremities. 

The  traction  should  be  respon- 
sible here  for  three  fourths  of  the 
correction  of  the  bad  position,  and 
the  pressure  for  less  than  one  fourth. 
This  applies  to  the  redressment  of 
direct  flexions. 

But  one  must  not  forget  that, 
generally,  there  are  lateral  devia- 
tions as  well. 

Scrutinise  thoroughly  the  diffe- 
rent elements  of  these  complex 
deviations,  of  Avliich  the  tAvo  most 
frequent  types  are  -.flexion  and  genu 
valgum ,  Jlexion  and  subdaxation  of 
the  tibia  outwards  and  backwards. 

You  act  upon  these  different 
factors  at  the  same  time.  Thus, 
whilst  an  assistant  makes  traction 
on  the  foot  to  correct  the  flexion, 
you  yourself  exert  all  your  strength 
on  the  upper  extremity  of  the  tibia, 
in  order  to  correct  the  sub-luxa'.ion, 
forcing  the  tibia  from  behind  for- 
wards and  from  without  inwards 
with  one  hand,  whilst  with  the  other,  you  push  the  femur  in 
the  opposite  direction  (fig.  554)- 

Repeat  the  movement,   persisting  for  several  minutes;  it  is 


Fig.  55 1.  —  Large  apparatus  «ilh 
aa  opening  allowing  the  treatment 
by  puncture  and  injections. 


Tin;    v\KM.()>i:s   roi.i.ow  inc    wiiiii.   swii.f.inc   f»r    iiin   knee      oaS 

necessary  lo  persist,  because,  il'llic  dcvialinii  he  ol  old  slaiidiuy, 
there  exist  osseous 
ficull  lo  canv  oul. 


there  exist  osseous  irregularities  which  render  redressment  dif- 


Fig.  552.  —   Slieep-sklu  gaiter  and  stirrup,  for  continuous  extension    of  the  knee  in 
wliite  swelling  (see  fig.  553). 

■       Complete  the  correction  at  two  sittings,  it  is  easier  for  yon 
and  better  for  the  patient.      In   this  way  you  tear  nothing.      I 


Fig.  553.  —  A  sand  bag  is  placed  on  each  side  of  the  knee  to  steady  it;  a  third 
sand  bag  is  placed  over  the  patella  and  assists  in  the  continuous  extension,  for  cor- 
recting the  flexion. 

speak  only  of  the  osseous  extremities,  for  injuring  the  popliteal 
vessels  and  nerves  is  scarcely  conceiyable,  in  spite  of  what  is  said 
in  certain  books  :  I  have  never  obseryed  it  in  my  own  practice. 

Correction  of  Ankyloses. 

Do  not  interfere  with  ankyloses  in  good  position.  Redress 
those  in  bad  position  —  by  the  method  I  have  just  described; 
it  is  always  (or  nearly  always)  possible  to  arrive  in  this  way, 
under  chloroform,  at  a  correction  of  very  old  standing  devia- 
tions, even  those  labelled,  Ankyloses  of  the  Knee. 


524   ANKYLOSIS  OF  THE  KNEE.  THE  COURSE  TO  FOLLOW 

A\hen  the  patients  are  anajsthetised,  if  one  examines  well, 
one  finds  some  indefinite  movements  in  the  joint;  but  this  very 
slight  mobility  is  sufficient  for  one  to  be  able  to  promise  the 
straightening-  of  the  knee  merely  by  manoeuvres,  which  sim- 
plifies matters  considerably.  Those  mana3uvres  you  already 
know  (fig.  5 54). 


Fig.  554-  —  Redressment  of  a  bad  position.  An  assistant  makes  strong  traction  in 
the  direction  of  tLe  deviation  ;  the  surgeon  applies  moderate  pressure  on  the  femur 
and  pushes  forwards  the  upper  extremity  of  the  tibia.  The  patient  is  held  firmly  by 
the  arm-pits,  and  by  the  medium  of  the  limb  flexed  over  the  abdomen  (fig.  /iSg 
and  liko). 

After  having,  for  some  minutes,  made  gentle  traction  and 
pressure,  you  fix  with  a  good  plaster  apparatus  the  partial  cor- 
rection obtained,  which  is  sometimes  scarcely  appreciable. 
The  traction  and  pressure  are  kept  up  Avhilst  the  plaster  dries, 
which  will  be  a  gain  of  several  degrees  —  and  so  you  leave  it 
for  i5  or  20  days.  After  which,  a  second  sitting  for  redress- 
ment, which  will  give  you  a  much  more  appreciable  correction. 

If  need  be,  you  make  a  third  correction,  and,  finally,  you 
have  corrected,  without  surgical  interference,  deviations  for 
which  some  other  practitioners  might  have  judged  a  resection 
or  an  osteotomy  indispensable. 


ilMI'I.I.     IIEDRESSMEM     NEAIU.\     AI.WVYS    SI  FFICIENT 


Fig.  555.  —  Osseous  ankylosis,  of  21  \ears  standing,  in  a  woman  tiiirty  years  of  age. 
Notice  the  complete  fusion  of  the  femur  and  tibia,  so  complete  that  there  is  a  medul- 
lary canal  in  the  osseous  bridge  which  unites  them.  Shortening  ii|  cm.  ^^  alks 
with  crutches.  —  The  patient  asked  to  be  redressed,  but  without  surgical 
operation.  If  impossible  to  effect  this  without  an  osteotomy,  she  would  prefer  to 
retain  her  infirmity,  however  inconvenient. 

Given  this  ultimatnm,  we  decided  upon  performing  osteoclasis.  For  that,  we 
strengthened  the  femur  and  tibia  with  wooden  splints,  '4  on  the  thigh,  i  on  the  leg, 
held  in  position  by  straps  (see  p.  40o,  fig.  ^66  ;  and  (under  anesthesia;  we  applied 
pressure  with  all  our  strength  (two  of  us)  so  as  to  increase  the  flexion  of  the  limb, 
the  femur  beins  held  bv  two  assistants.  After  two  or  three  minutes  of  effort,  the  limb 
gave  way  with  a  creaking  sound  and  became  flexed  at  an  acute  angle,  then  we  brought 
it  back  into  extension.      Large  plaster  for  two  months.   —  After  effects  very  slight. 


Fi".  556.  —  The  same  three  months  after  osteoclasis.  —  We  had  broken  the  bona 
at  exactly  the  spot  we  wished,  opposite  the  old  articulation.  One  sees  the  debris 
of  the  patella.  —  The  result  is  perfect.  Instead  of  19  cm.  of  shortening,  scarcely  a 
centimetre  and  a  half  remained  due  to  atrophy).  We  took  great  care  to  do 
nothing  to  restore  mobility  to  this  knee.  —  The  lameness  has  disappeared. 


526      MHITE    S^YELLING    OF    THE    K>'EE. 


ARTICULAR    INJECTIONS 


You  can  avoid  also  division  of  the  popliteal  tendons,  Avhich 
is  really  easy  Avith  the  technique  described  in  Chap.  xiii. 

(And  the  same  applies  to  the  case,  rather  rare,  of  osseous 
ankylosis.      It  would  be  quite  easy  to  perform  a  supra-condylar 

osteotomy  by  the  method  explained 
in  Chap,  x.) 

C.  The  Injections. 


S^sss^' 


The  culs- de-sac  of  the  knee-joint 
are  so  extensive,  so  superficial  and  so 
accessible  that  injections  here  are  par- 
ticularly easy,  provided  you  are  not 
dealing  with  a  chronic  Avhite  swelling 
of  several  years'  standing,  Avhere  the 
cavityis  obliterated  or  full  of  adhesions. 

Remember  that  the  interline  of  the 
/  .  joiiit  corresponds  with  an  horizontal 

)  passing  through  the  apex,  or  inferior 

angle  of  the  patella  (fig.  oSy). 
The  apex  of  the  patella  is  per- 
fectly appreciable  to  the  finger.      On 
;|^'^  each  side  of  it  one  easily  feels  a  de- 

pression. A  needle  pushed  into  the 
depression  would  penetrate  the  knee- 
joint. 

Here  already  are  two  points  of  access  to  the  joint. 
There  are  two  others,  at  a  centimetre  and  a  half  above  the  base 
of  the  patella,  and  at  a  centimetre  and  a  half  outside  (with  refe- 
rence to  the  axis  of  the  limb)  the  two  superior  angles  of  the  bone. 
If  one  punctures  there,  one  penetrates  into  the  sub-tricipital 
prolongation  of  the  synovial  cavity. 

As  a  general  rule,  it  is  into  this  external  part  of  the  sub- 
tricipital  prolongation  that  I  make  the  injections  and  I  advise 
you  to  make  them  there. 

One  can  make  the  cul-de-sac  bulge  out  at  this  external  point 


Fio-. 


557.  —  Points  of  access 
to  the  knee-joinl. 


Willi  I    ^w  1  I.I  i\(.   oi'    1  iin   KMcr 


b\  c\<'irniL:  |)i('-siiri' oil  llic  oilier  puiiil-.,  Uial  is,  ;iI)Oyc  and  on 
llic  iimrr  villi'  of  (he  palclla,  and  hdnw  it,  on  each  side  of  ihe 
patellar  liganuiil. 

Pliinire  vonr  needle  inio  the  snperior  exiei-nal  cnl-dc-sac.  not 
dii'ecllx  backwards,  hnl  a  lillle  down- 
Avards  and  inwards,  in  order  thai  (he 
poinl  enters  the  inler-condyloid  notch, 
between  ihtdeninr  and  the  under  surface 
of  the  patella.  "ion  will  feel  that  llir 
needle  is  at  once  enclosed  and  I'ree  bel- 
Aveen   the  tAAO  bones. 

\Yhen  you  baAe  this  sensation,  you 
are  sure  to  be  in  the  desired  position, 
exactly  in  the  articular  cavity. 

If  you  puncture  the  skin  too  near  to 
the  patella,  or,  if  the  obliquity  of  the 
needle  is  excessiAe,  you  run  the  risk  of 
striking  the  base  of  the  patella  and  mis- 
sing the  caA"ity.  Therefore  puncture  at 
a  centimetre  and  a  half,  or  cAen  tAA"o 
centimetres  above  and  outside  the  supero- 
external  angle  of  the  patella,  and  give 
the  needle  an  inclination  of  about  45°. 

You  ought  to  feel  the  femur  Avith  the 
extremity"  of  the  needle;  but  you  avoid 
driA'ing  the  point  into  the  bony  tissue 
because  this  might  break  it,  or  obstruct 

it,  Avhich  Avould  render  the  passage  of  the  liquid  impossible. 
Consequently,  you  push  the  needle  firmly  and  sloAAly  through 
tlie  soft  tissues  up  to  the  femur,  and,  Avhen  you  have  felt  the 
bone,  you  gently  AvithdraAv  your  needle  for  a  few^  millimetres; 
you  ought  then  to  feel  the  point  move  about  betAveen  the  patella 
and  the  femur.  At  this  moment,  you  should  push  in  the 
injection  Avithout  hesitation,  and  you  aaIII  see  a  SAvelling,  not 
only   in    the    sub-tricipital  cul-de-sac,   but  also  in   the  inferior 


Fig.  558.  —  Obliquity  is  gi- 
ven the  nee;lle  in  order  to 
be  sure  of  penetrating  into 
the  joint  cavity  idem, when 
one  penetrates  by  the  su- 
pero  external    cul-de-sac;. 


528        SURGICU.    OPERATIOX    I>'    WHITE    SWELLING    OF    THE    KNEE 

lateral  culs-de-sac,  on  each  side  of  the  apex  of  the  patella,  and 
YOU  will  at  the  same  time  see  the  patella  distinctly  raised. 

The  Injections  in  Old  }]'hiie  Swelling  of  the  Knee. 

In  old  standing  cases,  as  I  have  said,  it  may  be  that  the 
sub-tricipital  cul-de-sac  is  obliterated  or  cut  off  from  the  general 
cavity,  and  that  the  patella  is  adherent  to  the  inter-condylar 
groove. 

In  that  case,  if  you  would  be  perfectly  sure  that  you  have 
penetrated  the  cavity,  or  rather  what  remains  of  it.  puncture 
on  each  side  of  the  patellar  ligament,  exactly  in  the  interline ; 
puncture  someAvhat  obliquely,  going  from  the  lateral  point  to 
the  centre,  in  such  a  way  that  the  end  of  your  needle  reaches 
the  inter-condylar  groove,  exactly  behind  the  patellar  ligament. 

The  liqnid  introduced  at  these  points  cannot  take  a  false 
route;  it  will  penetrate  between  the  two  articular  surfaces  — 
when  there  are  interstices  between  them. 

At  the  same  sitting,  you  should  afterwards  make  a  second 
injection,  directly  into  the  sub-tricipital  cul-de-sac,  so  as  to  be 
certain  that   vou  have  readied  the  whole  of  the  affected  parts. 

After  the  classical  treatment  of  injections  thus  pushed  more 
or  less  freely  into  the  cavity,  should  the  patient  complain  of 
one  or  more  points  being  particularly  painful,  either  on  the 
outer  side,  or  above  the  interline,  one  may  infer  that  some  inde- 
pendent small  foci  persist,  which  have  not  been  reached  by 
the  injections  made  into  the  general  cavity. 

You  should  then  make  a  supplementary  series  of  injections 
into  the  painful  points,  pusliing  the  needle  up  to  the  surface  of 
the  bone,  beneath  the  periosteum. 

D.  Some  Remarks  on  Surgical  Operation  on  the  Knee  Joint. 

I  will  not  explain  the  technique  of  amputation  of  the  thigh 
and  Avill  not  delay  in  describing  to  you  all  the  surgical  opera- 
lions  which  have  been  performed,  or  proposed,  for  the  treatment 
of  AA'hite  swellinff  of  the  knee  :  erasion.  synovectomies,  arthrec- 


-w  ri.i.iN;.  oi'    iiii:   KM  I..  —  imviNAfii;  <»i    im:  .ioim- 


.r.i<j 


loniies,  —  ami  1  sli.ill  imi  do  so   Ix^causc  I  con>Itlcr  lliese  eco- 
nomic inlcrvciilidiis  In  he  had  nperalions. 

riiesc  ()|ioiali(>ns.  wliicli  dn  not  reach  hcNoiid  ihe  hmils  of 
the  disease,  have  Man  r|\  an\  advantage  over  rescclion.  They 
have  only  cured  while  ^welling  entirely  at  its  onset,  where  the 
lesions  Averc  alnmst  nil.  where  treatment  by  injections  or  even 
conservalive  treatment  woidd  have  been  sulTicieiit.  Thai  is  to 
say,  they  are  perfectly  useless;  to  their useJessness  one  must  add 
nearly  all  the  disadvantages  of  large  surgical  operations  :  ihc 
dangers  of  lisluhe.  ol'  luherculous  inicctiou,  etc. 

The  only  surgical  operation  you  will  sometimes  have  to 
perform  is  resection  of  the  knee-joint  in  adult  working 
people;  there  is  no  question  of  this  in  children,  Avliere  it  would 
be  disastrous  from  the  point  of  view  of  shortening  of  the  limb. 

What  you  may  chiefly  have  to  perform  is  drainage  of 
the  joint  for  articular  abscess  which  has  been,  bv  mistake  or 
simply  by  omission,  allowed  to  open.  —  and,  by  a  second 
error,  has  been  allowed  to  become  infected. 

a.  Technique  of  Drainage  of  the  Knee-joint. 

Take  care  to  open  the  joint  cavity  at  ils  most  dependent 
points  (fig.  559  and  56o). 

lou  know  that,  performed  methodically  as  it  ought  to  be, 
drainage  comprises  four  "  lateral  "  incisions,  parallel  to  the 
axis  of  the  limb,  two  on  each  side  —  seven  or  eight  centi- 
metres in  lenslh. 

The  tAvo  antero -lateral  incisions  run  along  the  sides  of  the 
patella,  the  two  posterolateral,  rather  smaller,  correspond  to 
the  two  latero-posterior  borders  of  the  condyles. 

These  two  last  incisions  replace  posterior  drainage  directly 
through  the  popliteal  space,  which  is  more  difficult  and  could 
only  be  done  by  opening  the  joint  freely  and  extensively. 

Through  each  of  the  anterolateral  incisions  one  inserts  a 
large  drainage  tube  through  to  the  postero-lateral  incision. 

"^  ou  will  foresee  that  one  could,  in  the  same  way.  join  the 

CviOT.  - —  Iiifllspensable  orlhopedics.  3.'i 


53o 


TECHNIQUE    OF    DRAINAGE    OF    THE    KNEE-JOINT 


two  an tero -lateral  incisions  by  two  supplementary  drains,  the 
one  passing  above,  the  other  below,  the  patella. 

The  internal  posterolateral  incision,  made  over  the  poste- 


Fig.  55g.  —  Drainage  of  the  knee-joint.  —  For  the  two  upper  incisions  and  the 
infero-internal  incision,  follo^Y  the  indications  in  the  diagram;  but  the  postero- 
lateral external  incision  ought  not  to  be  made  as  it  is  figured,  in  a  direction  perpendi- 
cular to  the  axis  of  the  limb ;  give  it  a  direction  parallel  to  that  axis,  so  as  to  be 
absolutely  sure  of  avoiding  the  external  popliteal  nerve. 

rior  border  of  the  internal  condyle,  does  not  require  very  great 
precision.  It  is  not  the  same  on  the  outer  side,  on  account  of 
the  presence  of  the  external  popliteal  nerve. 


Fio-.  5 Go. 


Knee-joint  viewed  on  the  inner  aspect.  —  The  different  incisions  giving 
passage  to  drainage  tubes  which  join  them  together. 


To  avoid  it  with  certainty,  one  must  take  as  a  land-mark 
the  tendon  of  the  biceps,  Avhich  is  easily  recognised  (fig.  786); 
the  nerve  is  a  centimetre  and  a  half  on  the  inner  side  of  the 
tendon.  One  has  therefore  only  to  keep  always  on  the  outer 
side  of  the  tendon  and  stojD  the  lower  end  of  the  incision  at  the 


^Vlll^L;  swkm.ing   or   Tiiii   ksee. 


UI::sEClIO.\ 


53 1 


arliciilar  iiilerlliic  (llic  iiilerliiio  corresponds  lo  llic  apex   of  the 
j^alella  Avilli  llie  Icj  in   llic  exicnded  posilion). 

(j.     On  resection  of  the  knee-joint 

One  will  linil  the  Iccliiiiqne  oC  reseclion  al  Icnglli  and  very 
well  described,  in  l''aral)enl"s  honk,  ijiie  we  will  make,  on 
ihis  subject,  simply  some  personal  remarks  wliidi  will  com- 
plete Avbat  you  already  know. 


I'ig.  50i.  —  Arrest  oT  liannorrliage  al'Icr  resection.  —  /"  step  :  one   places,  between 
the  t\YO  bleeding  osseous  surfaces,  a  compress  Iblcled  in  several  doubles. 

lou  will  use  an  Esmarcb's  bandage,  Avhicli  gives  you  greater 
facility  for  seeing  and  removing  the  diseased  parts. 

lou  perform  the  resection  of  the  two  articular  extremities 
with  a  small  saw  or  a  very  large  chisel,  —  a  resection  not  too 
extreme  nor  too  sparing,  so  as  to  remove  the  whole  of  the 
diseased  parts  of  the  bones,  cutting  for  a  fcAV  millimetres  —  not 
more  —  into  the  healthy  zone;  then  you  cut  away  all  the 
suspicious  soft  tissue,  Avitli  scissors  and  dissecting  forceps, 
expending  as  much  attention  and  lime  as  may  be  necessary. 


532 


WHITE    SWELLING    OF    THE    K>-EE 


The  toilet  of  the  bones  and  soft  parts  being  completed,  the 
exact    adaptation    of    the    surfaces    of  bone    Avell   ascertained, 


Fig.   562.  —   Second  step  :  the  limb  is  afterwards  placed  in  the  straight  position. 

place  some  compresses  between  the  surfaces  of  the  two  bones,  the 
leg  being  carefully  held  in  the  flexed  position;  you  place  tAvo 


Fig.  563.  —  Third  step.  One  or  two  other  compresses  are  placed  over  the  -wound  : 
the  surgeon  exercises  continuous  pressure  ^vith  both  hands  whilst  his  assistant  sup- 
ports the  foot  and  presses  the  limb  up^Yarcls,  with  the  foot  applied  to  his  breast. 

other  compresses  in  front  of  the  bones,  between  the  bones  and 
the  corresponding  soft  parts,  and  get  ready  to  apply  compres- 
sion, whilst  the  Esmarch  bandage  is  taken  off  (fig.  56 1  to  563). 
lou  press  very  exactly  in  this  way  for  ten  or  twelve 
minutes.  That  suffices  to  ensure  the  arrest  of  haemorrhage 
without    the    application  of  ligatures.      I    scarcely   ever  apply 


TE(;iiM(ji'i:  or   uesection  or    riir.  kM:i:-.i(»iNr  533 

li"aliucs    lo  the  small   vessels,   —  and    llio  advaiilafrc  is  groat 


Fig.  564.  Fig.  505. 

Fiij.   5o'i.  —  The  method  of  suturing;  the  skin  (overcasting  with  cat-gut). 
Fijj    5C5.  —  Suture  completed;  at  three  different  points,  strips  of  cat-gut  have  been 
inserted  to  ensure  drainage. 

in  not  leaving  any  foreign  bodies  in  the  wound,  in  order  to  be 
certain  of  obtaining  union  by  first  intention. 


Fig.  566.  —  Plaster  apparatus  furnished  with  an  opening  which  allows  of  inspection 
and  dressing  of  the  operation  wound  ;  it  is  closed  again  after  each  occasion  with  a 
plastered  bandage. 

If  bleeding  returns  after  twelve  minutes,  keep  up   the  pres- 
sure for  five  or  six  minutes  longer;  it  is  not  time  lost. 


534 


■WHITE     SWELLING    OF    THE    KNEE  JOI.XT 


If,  Avhich  YOU  rarely  see,  a  vessel  bleeds  again  at  this  time, 
it  is  quite  open  to  you  to  use  a  cat -gut  ligature,  but  vou  will 
still  gain  much  by  prolonged  pressure,  seeing  that,  in  place 
of  twenty  ligatures,  you  Avill  have  only  one  to  apply. 

Iloemorrhage  being  quite  arrested, 
you  pass  on  to  the  adaptation  of  the 
bones.  '\ouAvill  have  no  occasion  to 
suture  the  bones,  thanks  to  the  large 
plaster  which  you  apply;  you  suture 


Fig.  567.  —  Ordinary  sloc- 
king or  sleeve  of  jersev,  and 
a  lath  underneath  ;  for  moul- 
ding the  knee. 


Fig.  5G8.  —  A  celluloid  apparatus  for 
walking.  The  hip  and  ankle  are 
jointed  and  moveable.  The  knee  is 
ri^id  or  mobile  as  desired. 


the  skin  onlv  with  an  overcast  stitch  of  catgut  as  figured  here 
(fig.    564).    " 

This  suture  takes  a  minute  :  the  twelve  minutes  lost  in 
compression  are  regained  here. 

Three  strips  of  cat-gut  or  three  small  drainage  tubes  are 
inserted,  to  prevent  the  accumulation  of  the  sero-sanguineous 
effusion  in  the  wound  (fig.  565). 


TECHMQLE    OF    RESECTION    OF     llll-     kNEE-JOlNT 


53i: 


The  suture  of  (he  skin  ami  llic  thaina^^e  Jiiay  ihus  be  done 
Avilli  l)Oclies  winch  are  entirely  capable  of  being  absorbed. 

The  apparatus  is  here  of  capital  importance  and  merits  the 

closest  altoaliun.      It  is  a  large  plaster,  very  well  fitting,  which 

reaches  from  the  umbilicus  to  the  foot,  as 

I  slicun  here  (lig.  366).      One  commences 

\  I  by  making  the  part  of  the  apparatus  which 

extends  from  the  toes  to  the  root  of  the  limb. 


Fig.  569.  _   -  ^  Fig.  570. 

Fig.  56g.  —  Knee  apparatus  (in  plaster)  furnished   with  a  joint.  —    To  render  this 

jointed  knee  apparatus  moveable,  it  is  sufficient  to  cut  it  into  two  plastered  sheaths 

in  the  anterior  median  line  and  to  trim  the  edges. 

Fig.  570.  —   Knee  apparatus  in  celluloid,  serving  at  the  most  to  protect    the   knee 

but  not  sufficient  to  prevent  displacement. 

modelling  it  well  around  the  knee  and  the  malleoli,  then,  when 
the  setting  of  the  plaster  is  completed,  or  thereabouts  (after  waiting 
about  five  or  ten  minutes),  one  constructs  the  abdominal  portion. 
The  patient  is  placed  on  the  pelvi-support,  in  order  to  do 
this.  The  junction  between  the  abdominal  and  leg  portions  is 
easy  to  make,  wdth  a  few  turns  of  plaster  bandage  applied  as 
a  spica  from  one  to  the  other,  and  some  strengthening  squares 


536    ^THITE  SWELLING  OF  THE  R>"EE. APPARATUS  FOR  CONVALESCENCE 

(see  p.  ^20  for  the  method  of  construction  of  the  plaster  appa- 
ratus). A^  hen  the  h^st  bandage  has  been  apphed,  one  models 
the  apparatus  very  accurately  round  the  pelvis.  This  precision 
prevents  even  the  slightest  displacement  of  the  two  articular 
surfaces  placed  in  contact  Avith  one  another;  one  obtains  in 
this  Avav  perfect  union,  in  correct  position,  without  mentioning 
the  advantage  Avhieh  the  apparatus  has  in  ensuring  arrest  of 
hoemorrhage  and  the  prevention  of  all  inflammation  and  all 
pain  by  the  mathematical  immobility  which  it  affords. 

If,  which  is  very  unusual,  fever  should  supervene,  there  is 
nothing  to  prevent  one  making  one  or  more  temporary  ope- 
nings opposite  the  suture,  in  order  to  examine  the  wound  and 
rectify  the  drainage  (fig.  566). 

On  the  fiftieth  day,  one  removes  the  plaster,  replacing  it  by 
another,  or  still  better,  by  an  orthopoedic  apparatus  (fig.  067 
to  570)  with  which  the  2:iatient  will  be  able  to  walk,  after  a 
week's  rest,  at  about  the  sixtieth  day. 

But.  if  need  be,  the  patient  will  be  able,  being  provided 
with  the  large  plaster  apparatus  we  have  just  described,  to  get 
on  to  his  feet  ten  or  fifteen  days  after  the  operation  and  walk 
with  the  help  of  crutches. 

Convalescent  Apparatus  for  White  Swelling  of  the 
Knee  (v.  fig.  067  to  570). 

From  the  moment  of  being  placed  on  his  feet,  the  child  is 
supplied  with  a  large  apparatus  in  celluloid  (extending from  the 
umbilicus  to  the  toes),  similar  to  that  used  in  the  convalescence 
of  hip-disease —  with  the  difference  that  in  hip-disease  one  leaves 
the  hip  rigid  and  articulates  the  knee  and  foot  (of  the  apparatus), 
Avhilst  in  AAhite  swelling  of  the  knee  it  is  the  knee  (of  the  appa- 
ratus) Avhich  is  left  rigid,  the  hip  and  the  foot  being  arti- 
culated.     But  a  little  later  one  can  articulate  the  knee  in  its  turn. 

In  the  case  of  children  of  the  working  class  who  cannot  go 
to  the  expense  of  a  celluloid,  you  will  apply,  even  for  the 
period  of  convalescence,  a  plaster  knee  apparatus,  reaching 
from  the  trochanter  to  the  malleoli  (v.  p.  569). 


wiiiii:    --wiii.iM.   i>i     iiii:    WKir.-.ioiM 


l)lA(iN()>l- 


:>:'n 


WHITE  SWELLING   OF  THE   ANKLE-JOINT  ' 

a.     DIAGNOSIS     ITS    PECULIARITIES) 

In  adolescents  willi  allcdious  of  the  auklc-joiul,  il  is 
ntcessary  lo  guard  againsl  mistaking  a  simple  iarsaUjia  lor 
luljerculous    arthritis.      It    is  sufficient    lo    remember    this   in 


Fig.  571.  —  Skeleton  of    the    ankle- 
joint,  posterior  view. 


2  cerU:^ — I 


Fio;.  5t-2. — The  same,  anterior  view:  measure- 
ments to  find  the  places  of  election  in  the  adult. 


order  to  preA^ent  error.  The  conformation  of  the  foot  (the 
bulging  on  the  inner  side  of  the  astragalus  and  scaphoid,  the 
deviation. of  the  foot  on  the  outer  side  in  abduction,  the  sole  of 
the  foot  generally  very  flat),  the  absence  of  appreciable  fun gosi- 
ties,  enable  one  to  make  the  diagnosis  (v.  also  Tarsalgia,  chap.  xn). 

I.   See  thesis  of  D'  Balcncic,   igo'i. 


538         WHITE    SWELLING    OF    THE    ANKLE-JOINT.     ^    PROGNOSIS 

b.     PROGNOSIS 

It  is  here  particularly  favourable  :  cure  is  nearly  ahvays 
effected  with  preservation  of  movements. 

The  functional  result  to  he  aimed  at. 

Follow  the  same  general  principles  as  for  the  knee.  They 
will  conduct  you  to  a  complete  cure. 

If,  in  a  very  exceptional  case,  the  foot  become  stiff,  do  not 
endeavour  to  alter  this,  as  long  as  the  position  is  good.  Moreover, 
if  the  ankle  has  preserved  some  amount  of  movement,  but 
retains  a  certain  equinism,  which  makes  the  patient  lame,  do 
not  hesitate  to  place  the  foot  at  a  right  angle  and  keep  it  so 
with  a  plaster  as  long  as  is  necessary  so  as  to  secure  a  good 
position,  at  the  risk  of  ankylosis  occuri ng. 

The  play  of  the  neighbouring  articulations,  the  sub-astra- 
galoid  and  the  mid-tarsal,  will  supplement,  in  great  measure, 
this  stiffness  of  the  ankle,  which  may,  perhaps,  be  only  tem- 
porary. 

c.     PARTICULARS  OF  THE  TREATMENT 

I"'    The  injections 

First,  some  anatomical  points  to  establish  the  technique  of 
the  injections  (fig.  671  to  575). 

The  synovial  cavity  of  the  ankle-joint  permits  of  the  needle 
entering  in  front  at  one  of  the  lateral  angles  of  the  interline,  and 
also  behind,  at  the  external  part  by  preference,  away  from  the 
posterior  tibial  vessels.  In  front,  one  will  easily  avoid  the  anterior 
tibial  artery  and  vein,  placed  in  the  middle  of  the  anterior  surface. 

It  is  necessary  to  use  fine  needles  (n"  i,  or  at  most,  n"  2, 
of  Collin).  The  internal  angles  will  be  wider  if  the  foot  is 
carried  outwards,  and,  inversely,  the  external  angle  will  be 
wider  if  the  foot  is  carried  iuAvards. 

As  a  general  rule,  I  make  the  injections  in  front,  alterna- 
tely on  the  inner  and  outer  sides  (fig.  57/1)  of  the  interline 
(over  the  lateral  angles). 

But  if  you  find,  at  your  first  visit,  an  appreciable  swelling 


\U1ICLI.AU     IN.II'CTIONS     INTO    Till:     A  NK  I.K-.K  »INT 


b'.ii) 


of  llic  serous  t'avil\  at  aiiollicr  poinl,  it  is  llicre,  in  lln'  fciilrr 
of  Mil'  riini^niis  mass,  qiiilc  accessible,  lliat  you  convey  llie 
moclilying  li([irul. 

It  is  in  fronl,  or  alniosl  as  IVcquenlly  in  llic  dependent 
pail'^  behind,  against  the  malleoli,  or  even  close  lo  the  lendo 
\('liilli>.  dial  liiei^c  liingous 
masses  arc  prod  need.  W  hen 
ihey  become  apparent  at  ihe 
second,  third,  or  lourth  in- 
jection,   the    treatment   be- 


Fig.     5-3.     —     Transverse 
section  of  ttie  ankle-joint. 


Fig.  5-3  bis.  —  One  penetrates  at  tlie  antero- 
external  angle  of  tlie  tibio-larsal  joint.  It 
is  not  necessary  to  pusli  tlie  needle  so  far  in  as 
is  shewn  liere. 


comes  much  easier.     The  injection  and  the  puncture,  if  there 
is  fluctuation,  are  made  at  these  points. 

If  at  the  same  time  there  are  an  anterior  and  a  posterior 
projection,  we  will  choose  the  latter  by  preference,  because 
behind,  the  synovial  cavity  is  much  further  removed  from  the 
skin  than  in  front  and  we  are  all  the  more  secure  from  the 
risk  of  producing  a  fistula.  One  may  see  indeed,  sometimes, 
the  skin  give  way  in  front,  after  too  great  distension  of  the 
cavity  of  the  joint  in  the  course  of  treatment  by  the  injections. 


54o       WHITE    SWELLING    OF    THE    ANKLE-JOINT.     INJECTIONS 

But  it  is  a  simple  rupture  of  the  skin  through  excess  of  tension, 


^:^- 


Fig.  574.  —  Mew  of  the  external  aspect  of  the  joint  after  injection  into  the  synovial 

cavitv 


Fig.  575.  —  One  of  the  two  points  of  election  for  penetrating  the  joint. 

that  is,  a  non-infected  fistula.      It   is    sufficient  to  discontinue 


THE    APPARATUS    lOU     I  III:    A\  kl.K-.IOlM 


5^1 


llie   iiijectioiis  ;iiul    lical    (li(>   pari    willi  gooil   asc|»tic  dicssiiigs 


Fig.   576. —  Plaster  for  llie  anlvle   :  position    of  the  surgeon's  hands  durint;  the  drvin;< 

of  the  apparatus. 

for  a  week  or   two,  to  see  it  close.      One  then  returns    to    the 
injections,   if  one   lias 
not  already  given  the 
requisite  number. 

2^"'     The  Apparatus 

ifig.  57G,  577). 

This  reaches  from 
the  toes  up  to  the  in- 
terline of  the  knee,  or  at 
least  up  above  the  calf. 

One  must  take  great 
care  to  place  the  foot 
exactly  at  a  right  an- 
gle and  even  at  an  angle 
slightly  acute,  as  a  pre- 
ventive measure,  becau- 
se of  the  natural  ten- 
dency of  the  foot  to  take  ^^'-  '''■  -  'fl-  ;ame  finished  with  an  opemn, 
-'  opposite  llie   external  malleolous. 

on    extension ;    for   an 

analogous  reason,  in  liip-joiut  disease,  we  place  the  thigh,  as 

a  preventive  measure,  in  hyper-extension  and  slight  abduction. 


54a       ^VHITE    SWELLING    OF    THE    ANkLE-JOINT.    DEVIATIONS 


Instead  of  making  an  opening  at  the  anterior  part,  through 
which  to  make  the  injection,  we  prefer  to  make  a  bivalve  appa- 
ratus, anterior  and  posterior,  or  lateral,  in  such  a  way  as  to 
be  able  to  remove  it  at  each  new  injection  (v.  fig.  42,  p.  59). 
This  allows  of  a  more  complete  exploration  round  the  joint. 

The  puncture  and  injec- 
tion being  made,  and  a  slight 
dressing  applied,  one  re- en- 
closes the  leg  and  the  foot, 
taking  great  care  to  replace 
the  heel  very  exactly  in  the 
most  dependent  part  of  the 
apparatus  in  such  a  Avay  as 
to  restore  it  to  a  rig'ht  angle  : 
Avithout  this  the  foot  acquires 
spontaneously  a  position  of 
equinism.  In  this  way  one 
prevents  deviation. 

One  uses  these  bivalves 
again  in  cases  where  there 
are  multiple  fistulas. 


Deviations. 


Fig.  578.  —  Taking  a  mould  of  the  ankle 
(v.  p.  97).  Ordinary  stocking  split  at 
the  ends  of  the  toes  A  strip  of  zinc  is 
placed  under  the  stocking  upon  the  skin. 


If  the  foot  has  already 
become  deviated,  you  will 
know  the  way  to  correct  it 
during  the  course  of  treatment  by  injections.  To  do  that,  you 
Avill  make,  after  each  injection  (or  every  two  sittings)  a  new 
small  plaster,  Avhich  takes  two  minutes  (two  bandages  to  roll) ; 
before  the  plaster  is  set,  you  endeavour  to  gain  a  few  degrees 
of  correction  by  a  gentle  but  sustained  pressure  of  your 
hand  applied  to  the  sole  of  the  foot,  while  the  other  hand 
firmly  supports  the  leg  portion  of  the  bandage. 

As  to  the  deviations  observed  in  a  white  swelling   already 
cured,   the    simplest  way  to    obtain   the  correction    is   with    a 


\i'i'AU\Tis   !-(»ii   i'K()Giu>-si\  i:  (:()iuu:cTio\ 


543 


Fig    579.  —  Mould   of  llie   foot    wilb 
strengthening  pieces. 


Fig.  58o.  —  Celluloid  apparatus  with 
clastic  bands  for  the  progressive 
redressment  of  the  foot. 


Fis:    58 1.  —  For  the  progressive 
redressment  of  the  foot. 


Fis:.  082.  —  Plaster  apparalus 
with   a  joint. 


044 


MEDIO-TAJISAL    ^VHITE    SAVELLOG 


series  of  plaster  apparatus,  such  as  we  have  described. 
One  could  use,  in  place  of  a  plaster,  an  articulated  apparatus 
in  celluloid  or  leather,  to  the  anterior  part  of  which  might  be 
attached  two  elastic  bands  cross-wise,  to  approximate  the  two 
articular  levers  (fig.  078  to  583).  One  might  also  correct  old 
standing  deviations,  particularly  the  lateral  deviations  in  valgus 


Fig.  583.  —  Bonnetss  apparatus  for  mobilisation  of   tlie   ankle.      But.   if  vou  are  not 

a  specialist,  keep  it  for  stiff  joints,  not  tuberculous  ones. 

or    varus,    with   the    lever    boot    which    we    use    for    club-foot 
(v.  Chap.  xiv).     In  a  general  way,  do  not  interfere  with  anky- 

losed  joints  which  are  in  good  position. 

WHITE   SWELLING   OF  THE   MEDiO-TARSAL  AND   SMALL 
JOINTS  OF  THE   FOOT 


Here.  also,  take  care  not  to  mistake  a  white  swelling  for  a 
tarsalgia,  and  conversely.  A"\  e  have  mentioned  liow  the  dia- 
gnosis is  made  (v.  also  Chap,  xii). 

One  treats  a  medio-tarsal  arthritis  like  an  arthritis  of  the 
ankle  (see  above). 

When  one  is  dealing   with  the   small    articulations   of  the 


WHITE    SWELLING    OK     llli:    SALVLL    A  UTKULATIONS   OF   THE    EOOT     5/|5 

foot,  it    becomes   vcin    dil'licult   to    push   llic  injecllon    into   the 
joints  when  tliey  are  so  compressed  logclher  (fig.  5(S/|,  .jcSo). 


Fig.  58^.  —    Medio-tarsal  joint,  seen  on  its  external  surface;  llie  point  of  election  is 
at  2  0  millimetres  in  front  of  the  external  malleolus  (in  adults). 

On  the  other  hand,  one  must  know   that  by  reason  of  their 

t 


•  15  yn  I  2i  =•/,, 


Fig.  585.  —  Tlie  same,  viewed  on  the  inner  side  :  the  point  of  election  is  at  i5_milli- 
metres  behind  the  tubercle  of  the  scaphoid  ;  at  22  millimetres  from  the  tip  of  the 
internal  malleous. 

superficial  situation,  ahnost  sub-cutaneous,  the  skin  on  the 
dorsal  aspect  is  constantly  in  danger,  either  from  punctures 
which,   in  course   of  time,    diminish    its    resistance,    or  (from 

C^LOT.  —  Indispensable  orthopedics.  35 


546        WHITE    SWELLI>G    OF    THE    SMALL    JOOTS    OF    THE    FOOT 

AYithin  out)  from  fungosities.  It  is  necessary  then  to  redouble  the 
precautions  to  avoid  the  opening  of  white  swelhngs  of  these 
small  joints. 

If  there  is  a  prominent  spot,  for  example  a  projecting  fun- 
gosity,  on  the  plantar  aspect,  through  which  you  can  reach 
the  joints,  make  use  of  it;  the  effusion  which  you  will  setup 
Avill  easily  find  its  way  between  the  bones  and  the  fleshy  masses 
of  the  sole,  and  the  skin  will  easily  be  saved. 

If  it  is,  on  the  contrary,  towards  the  dorsal  aspect  of  the  foot 
that  the  fungosities  point,  especially  if  they  have  already  com- 
menced to  erode  the  deep  surface  of  the  integument,  you  are 
obliged  to  attack  them  there.  —  Then,  inject  with  a  fine  Pravaz 
needle  (puncturing  outside  the  invaded  points)  a  but  slightly 
''irritating"  liquid,  and  in  a  small  dose;  inject,  for  instance,  a 
few  drops  (6,  8,  lo)  of  creosoted  oil  with  iodoform  (rather  than 
camphorated  naphtol,  which  Avould  occasion  a  too  vigorous 
reaction). 

If  a  liquid  effusion  is  produced  with  some  degree  of  tension, 
make  haste  to  evacuate  it,  either  by  slight  pressure  made  through 
the  skin,  after  puncturing  Avith  a  n°  i  or  n"  2  needle,  or  by 
means  of  an  aspiration  in  the  ordinary  Avay,  taking  care  that 
you  do  not  use  a  larger  needle  than  n°  3,  —  n°  4,  Avouldhere 
endanger  the  integrity  of  the  skin. 

Then,  again,  inject  a  few  drops  of  creosoted  oil,  and  carry 
on  the  treatment  by  combining  the  two  desiderata  of  preserving 
the  asepsis  of  the  joint  and  not  causing  a  fistula  to  develop. 

Some  succeed  where  others  fail.  It  is  a  matter  of  attention 
and  slightly  also  of  skill. 

When  the  skin  gives  way,  if  it  is  not  at  the  beginning,  if 
one  has  already  been  able  to  make  some  injections  of  modifying 
liquid  and  to  partially  sterilize  the  tissues,  little  harm  is  done; 
cicatrisation  is  generally  obtained  in  five  days  after  the  rupture 
of  the  skin. 

In  order  to  secure  the  healing  of  the  ulcerated  skin,  follow 
the  treatment  indicated  on  p.  i6i. 


WIIME    SWI.LI.ING    OK    Tlin     Ll'I'CU    I.IMIl 


5/17 


WHITE  SWELLINGS  OF  THE  UPPER  LIMB 


White  swellings  ol'  (he  upper  liiiilj   are  less   IVeqiieiil   llian 
lliesc  of  the  loAver  limb,  because  the  laller  underi-o  more  Aili'nie 


Fig.   580.   —  How  to  make  a  plaster  apparatus  for  the  upper  limb. 
7"  slep.  —  Circular  turns  round  the  trunk  :  the  plastered  bandages  are,  as  in  other 
parts,  applied  over  a  vestment  which  is  either  an  even  layer  of  cotton  wool  of  four 
or  five  millimetres  thickness  or,  which  is  better,  an  ordinary  jersey. 


than  the  former;  they  attain  a  much  less  serious  degree  in  the 
arms,  and  they  are  cured  more  easily  for  the  same  reason. 

It  folloAYs  again  that  the  deviations  are  less  marked  and 
complex  apparatus  are  less  often  necessary,  or  are  required  for 
a  much  shorter  time,  in  the  upper  than  in  the  lower  limb. 


548 


WHITE    SWELLING    OF    THE    UPPER    LIMB 


F^One  may  ensure  the  repose  of  the  arm  or  the  fore-arm  with 
a  simple  sling,  adding  to  it,  it  goes  ^Yilhout  saying,  a  shghtiy 
compressive  wool  dressing  to  protect  the  affected  joint.  If, 
hoAA'ever,  the  pain  is  considerable  or  the  nature  of  the  swelling 
somew^hat  serious,  it  would  be  quite  simple  to  immobilise  more 


Fig.  587.  —  How  to  make  a  plaster  apparatus  for  the  upper  limb.  2'"'  s/ep.  A  roller 
bandage  is  carried  backwards  from  the  axilla  of  the  sound  side  (i)  to  the  affected 
shoulder  (i  bis.);  it  is  then  carried  down  over  the  anterior  surface  of  the  arm 
making  a  bend  beneath  the  flexed  elbow  (2),  it  passes  upwards  behind  and  crosses 
over  the  shoulder  (3);  one  then  makes  several  turns  of  Ihe  same  spica,  the  diffe- 
rent spirals  overlapping  each  other  (see  the  first  step  in  fig.  58(3). 

completely  the  affected  region  by  replacing  the  soft  strip  of 
wool  dressing  by  a  few  plastered  strips. 

It  is  here  that  moveable  plasters  or  bivalve  plasters  are 
chiefly  employed;  we  have  given,  page  92,  the  method  of  con- 
structing them. 

With  the  plaster  apparatus  —  which  abolishes  pain  at  once 
—  the  patient  is  at  liberty  to  Avalk  about. 

The  diagrams  here  given  represent  the  different  apparatus 
which  you  may  apply,  according  to  the  case,  to  the  upper  limb. 


TLASTEIl    Ari'ARATlS    FOIl     '1  III:    AIlM 


r^Vj 


This  is  the  I.ir-^o  |il;islci-  wliicli  sccinvs  \\ir  ininioliilis.ilion 
of  llic  entire  liinl),  in  llie  case  of  |i;iinriil  while  swelling-  nl'  ihc 
sliouldor  (fi,i^-.  \')S()  ti)  590). 


Fig.  588.  —  The  teclmique  of  a  large  plaster  for  the  upper  limb  'continued). 
3"'  step.     One  makes  circular  turns  round  the  arm. 


The  large  apparatus  for  white  swelling  of  the  elbow  is 
identical  Avitli  the  preceding. 

Fig.  591  represents  the  medium  plaster  for  the  elbow.  One 
sees  by  these  diagrams  tlie  position  in  which  the  upper  limb 
is  immobilised  : 

The  arm,  in  an  abduction  of  from  lo"  to  20°; 


55o 


WHITE    SWELLINGS    OF    THE    UPPER    LIMB 


The  elbow  in  the  position   of  flexion  at  a  right  angle  or, 
better,  at  an  angle  of  70°  to  80"  (with  the  arm). 


Fig,  58g.  —  Apparatus  for  tlie  arm  (continued). 
-S""  step.     One  finishes  by  circular  turns  round  the  arm,  the  forearm  andthe  wrist. 


The    wrist,    in    a  straight    position,    A^dthout    flexion,    but 
without  hyper-extension. 


WHITE    SWELLING    OF    THE    SMori.DFU .     r\\E    l\,in(:Tir)NS       0  J I 


A.   -   WHITE  SWELLING  OF    THE  SHOULDER 

Technique   of    the    injections.      -     I'ig.    690    shews    llic 
analomy  ol'  llie  joiul  and  llie  cxlciiL  ol'  the  synovial  membrane. 


%mA 


Fig.  590.  —  Apparaius  for  the  upper  limb   completed,  furnished  with  openings  oppo- 
site the  different  articulations. 


There  are  several  points  Adhere  one  can  reach  the  synovia. 
Keep  only  to  the  two  following; 

I'*.  On  the  outer  side,  in  the  bicipital  cul-de-sac  of  the 
general  cavity  of  the  joint; 


552  WHITE    SWELLING    OF    THE    SHOULDER 

2"'^.  In  front,  between  the  coracoid  process  and  the 
bicipital  groove. 

It  is  the  second  route,  that  is,  the  anterior  route,  which 
I  advise  you  to  follow  in  all  cases  ^  (fig.  SgS).  The  pointed 
coracoid  process  is  always  easy  to  feel,  even  in  fleshy  subjects 
(fig.  595),  at  the  antero-internal  part  of  the  bony  vault  of  the 


Fig.  5gi.  —  Medium  apparatus  for  the  upper  limb  immobilising  the  elbow  and   the 
■wrist  (one  can  easily  make  it  a  bivalve). 

shoulder.  From  the  bony  point  of  the  coracoid  process,  go 
horizontally  outwards  : 

To  half  a  centimetre  of  the  process,  in  a  child; 

To  one  centimetre  in  an  adult;  and  push  in  your  needle  at 
this  point,  from  before  backwards  and  a  little  (i5°)  upwards. 
You  feel  the  head  of  the  humerus  with  the  extremity  of  the 
needle,  and  it  will  be  easy,  on  manipulating  the  humerus,  to 
assure  yourself  that  you   are  well  upon  the  head  of  the  bone. 

That  done,  you  withdraw  the  needle  for  one  or  two  milli- 
metres and  then  push  in  your  injection. 

If  you  inject  every  day,  you  will  find  some  fluid  collected 
by  the  third  or  fourth  day. 

I .   BecavTse  it  is  rather  difficult   to   make    the  liquid  penetrate  the  bici- 
pital cul-de-sac. 


I'lilMS   OF  ACCESS   TO    rill-    AKIICII.AR    CAV1I\    or    HIE    Mioil.hlll     ')')'.\ 

One  sliniiKl  know  thai  il  accuinulales  at  the  posterior  pari 
especially,  or  in  llio  must  depcndcnl  pari  of  llio  Joint  rallier 
than  in  honl. 

Il  is  iherolbrc^  in  ihc  hack    |)ntl  oC  the  shonhlcr  (or  even  at 


Fig.  592.  —  One  punctures  at  one  cenlimetre  outside  the  coracoid  process. 

the  posterior  part  of  the  axilla)  that,  from  the  third  or  fourth 
day.  you  will  find  fluctuation,  although  you  have  made  your 
injections  in  front. 

AA  hen  fl actuation  is  appreciable  at  some  point,  you  puncture 
there.  —  But  if  you  prefer  to  puncture  only  in  front,  you  can 
cause  the  whole  of  the  fluid  to  move  towards  this  point  by 
pressing  Avith  the  flat  hand  over  the  opposite  dependent  part  of 
the  collection  in  the  joint. 

One  makes  the  necessary  ten  punctures  and  injections;  after 
which,  one  empties  to  the  bottom  the  articular  cavity,  by  two 
supplementary  punctures,  without  the  consecutive  injections. 
During  this  treatment,  as   Avell   as   after  it,   one   supports   the 


ooa 


TSHITE    SWELLING    OF    THE    SHOULDER 


shoulder   merely  with    a  Velpeau  bandage.    Avliich   covers    the 
dressing:  and  with  a  sling,  which  supports  the  arm. 

It  is  only    in  acutely  painful  cases  that   one  would  apply 


Fig.   593.  —  Shoulder  joint  afler  injection  of  tlie  synovial  cavity.      The  sketch  she\YS 
the  different  points  by  Avhich  one  can  reach  it  ^vitli  the  needle. 

the  large  apparatus  (in  the  way  indicated  above)  Avith  an 
opening  over  the  anterior  part  of  the  region  through  which  to 
make  the  necessary  injections.  But  this  plaster  apparatus  must 
he  removed  immediately  the  pain  has  disappeared,  for  instance 
1 5  or  20  days  after  the  cessation  of  the  injections. 

One  does  not  therefore  ever  make  a  strict   and  prolonged 
immobilisation  of  the  joint. 


VUIICIIVU     INJECTIONS    INTO     THE    SIKH  I, HI  U     .loIM'  ;);)a 

Tlic  ;i(l\aiilat:v  ol'  lliis  course  is.  llial  \\\o  niovcnienls  of  the 
joiiil  lia\('  ii(~il  liinc  lo  Ix'  losl.  at  least  coin|)letel  \ ,  anc]  tlial 
the\  leluiii  ^eiKMalK  in  the  lii>t  lew  weeks  which  lolldw  the 
ciul  ol'  acti\e  liealiiieni . 


Fig.  Sgi.  —  The  needle  may  be  forced  between   the  acromial  vault  and  the  head  of 

the  humerus. 


They  return  spontaneously.  The  patient,  when  he  no  longer 
suffers,  instinctively  extends  the  field  of  movement  of  the  shoulder. 
A  little  later,  he  makes  use  of  his  arm  for  slight  purposes, 
Avithout  actually  imposing  hard  w^ork  upon  it,  for  several 
months  more. 

To  aid  the  return  of  mohility,  one  orders  the  patient  daily 
baths  :  the  baths  of  Bareges,  of  Argeles-Gazost,  of  Bourbonne, 
etc.,  etc. 


556       AXKTLOSIS    OF    THE    SHOULDER    FOLLOWIXG    WHITE    SWELLING 

The  treatment  of  fistuke  presents  nothing  you  do  not  already 
knoAY  after  having  read  the  first  part  of  this  chapter. 
As  to  function.     Stiffness  and  Ankylosis. 

AA  e  have  stated  that  if  the  arm  has  not  Ijeen  strictly  immo- 
bilised bevond  a  few  months  —  and  this  Avill  not  be  so  bv  the 


Fig.  bcjo.  —  TLe  point  of  election  for  the  injections  is  found  at  one  centimetre  outside 
the  coracoid  process,  which  is  always  easily  felt. 


treatment  with  articular  injections  —  the  movements  will  not, 
as  a  rule,  be  lost. 

If  you  find  yourself  in  the  presence  of  a  complete  ankylosis, 
do  not  interfere  with  it;  it  is  safer. 

lour  patient  is  well  cured,  thanks  to  the  supplementary 
and  compensatory  mobility  of  the  scapula;  and  you  Avould  run 
too  much  risk  of  aggravating  the  situation,  instead  of  improA'ing 
it,  bv  undertaking  the  forced  mobilisation  of  the  ankylosis. 

It  is  especially  the  business  of  specialist  surgeons,  Avorking 
in  orthopoedic  institutions,  to  undertake,  in  certain  cases,  these 
attempts  at  mobilisation  (fig.  096). 


AMIITE     S\\F.II.1N(;    or    Till'     ELBOW.     INJECTIONS  JOT 


Fio-.   ogG.  —  Melliod  of  fixino:  the  stump  of  the  shoulder. 


B.  —  WHITE  SWELLING  OF  THE  ELBOW 

In  the  elboAV,  as  in  the  knee,  the  technique  of  the  injections 
is  particularly  easy.  One  enters,  either  by  the  radio-humeral 
interline,  which  one  feelsover  the  external  border  of  the  elbow — 
making  movements  of  rotation  in  the  fore-arm — or.  by  preference, 
a  few  millimetres  above  the  point  of  the  olecranon,  because 
the  route  is  here  wider  and  more  accessdile  (fig.    697  to  599). 

In  flexing  the  fore-arm  to  a  right-angle,  one  easily  feels  the 
point  of  the  olecranon,  and  above  it  the  tendon  of  the  triceps 
stretched  in  this  position.  It  is  sufficient  to  puncture  at  3  or 
!\  mdlimetres  above  the  bony  point,  and  outside  of  the  middle 
of  the  tendon  to  penetrate  easily  and  surely  into  the  joint  cavity. 

After  a  few  injections,  the  supra-olecranon  cul-de-sac 
becomes  distended,  and  the  technique  becomes  still  more 
easv.  The  synovial  cavity  is  placed  so  far  from  the  skin  that 
one  here  runs  no  risk  of  fistula. 


558 


WHITE    SWELLING    OF    THE    ELBOW, 


BAD    POSITIONS 


Bad  Positions.  The  elboAv  ought  to  be  at  an  angle  of 
from  70°  to  80°,  in  the  case  where,  in  spite  of  every  care, 
ankylosis  has  occurred  (v.  fig.  591,  p.  SBa). 

If  it  is  not  in  that  position,  one  must  place  it  there,  by  stages, 


Fig.  597.  —  The  elbow  joint  seen  on  its  external  aspect  :  the  radio-humeral  articula- 
tion is  found  at  i8  millimetres  from  the  tip  of  the  epi-condyle. 

making  partial  corrections  followed  by  the  application  of 
small  plasters,  recommencing  every  eight  or  fifteen  days  with  a 
ncAV  correction. 

Stiffness  and  Ankylosis.  The  movements  nearly  always 
return  spontaneously,  provided  that  one  has  not  uselessly  pro- 
longed the  immobilisation  by  plaster  apparatus.  That  is  why 
we  generally  keep  it  up  simply  with  soft  bandages.  Leave 
the  movements  to  return  of  their  own  accord  —  helping  them, 
after  five  or  six  months  of  waiting,  by  baths  or  by  slight  gently 
passive  movements,  made  by  the  patient  himself,  in  this  way  : 

The  arm  is  held  by  two  straps  or  by  some  person's  hand, 
on  the  surface  of  a  table,  the  patient  being  seated.  With  the 
sound  hand,  he  takes  his  stiffened  fore-arm  and  makes  slight 
movements  in  every  direction  :   flexion  and   extension,  prona- 


STU-FNF.SS     AM)     WK'iLUSlS    or     Till:     lOII'.OW.     IllKATMENT       .ij[) 

lion  and  supination.     In  this  \\;i\   we  have  obtained  sonic  very 
excellent  cures  (sec  also  fi;.'-.  601). 


Fig.  098.  —  The  needle  strikes  Ihe  arliculation  by  (he   supero-external  angle  of   the 
olecranon  and  penetrates  into  the  olecranon  cavity. 


^Yhat  we  are  noAv  going  to  describe  relates  exclusively  to 


incomplete  fibrous  ankyloses. 


.-^^ 


1    2  cent.     ! 


Fig.  599.  —  The  elbow  joint   seen  on    its  internal    aspect  :  the  ulno-humeral  inter- 
line is  found  in  the  axis  of  the  ulna,  at  two  centimetres  from  the  epitrochlea. 

In  the  case  of  a  patient  coming  to  you  with  a  complete 
osseous  ankylosis,  do  not  interfere  with  it  if  the  position  is 
good,  that  is,  if  the  elbow  is  flexed  at  an  angle  of  from  70° 
to  80°. 

If  the  ankylosis  is  bad  (the  elbow  in  complete  exlensiou), 


56o 


AVIIITE    SWELLING    OF     THE    ELBOW 


correct  it  by  an  iacompiete  osteotomy,  making  use  of  artificial 
fracture,    or,  just   as   well,  keep   exclusively  to  manual  osteo- 


Fig.   600.  —  Injection  into  the  elbow  joint. 

clasis,  which  you    may    perform    in    the   following    manner  : 
Some  wooden   splints  are  placed  round  about  the  arm,  and 


Fig.  601.     -  Jointed  dial  apparatus  for  mobilisation  of  ibe  elbow.      To   effect  flexion, 
one  can  join  the  two  levers  with  elastic  cords. 


STIFFNESS    A^D    ANKYLOSIS    OK    THE    E^.nO^\  .     TUEATMEN'I'      50 1 

others  around  llie  lore-arm.  \\  luls.1  the  arm  is  firmly  held, 
you  seize  the  fore-arm  with  bnih  hands  and  cnrrv  it  in  the 
direction  of  flexion.  Separation  takes  place  at  the  iiilerhne. 

The  fore-arm  heing  llexetl  at  a  rip-hl  an<^le,  you  fix  it  in 
that  position  with  a  plaster  Avhich  you  leave  on  for  two  or  three 
weeks;  after  thai.  \ou  lake  olf  the  plaster  and  order  haths  and 
massage. 

As  a  rule,  ankylosis  is  reproduced,  hut  in  a  very  good  posi- 
tion. Sometimes  you  may  be  fortunate,  enough  to  see  useful 
movement  return. 

A  resection  might,  exceptionally,  enable  you  to  restore  some 
amount  of  movement  —  but  how  rarely!  —  and  scarcely  ever 
without  prejudice  to  the  strength  of  the  arm  —  so  that,  every- 
thing considered,  I  dare  not  advise  you  to  have  recourse  to  that 
operation  —  provided  that  the  elboAv  is  ankylosed  at  a  right 
angle. 


Calot.  —  Indispensable  orthopedics.  3G 


562 


TilllTE    SWELLOG    OF    THE    WRIST 


C.  —  WHIT£  SWELLING  OF  THE  WRiST  AND  OF  THE   SMALL 
ARTICULATIONS  OF  THE  HAND 

i^*  White  Swelling  of  the  Wrist. 

Anatomy.  —  The  two  extremities  of  the  interhne  are  easily 
found.  The  centre  of  the  interhne,  in  the  aduh,  is  found  at 
from  6  to  7  millimetres  above  the  straight  line  connecting-  the 


two  apophyses  (fig.  602). 


Fig.  602.  —  The  point  of  elec- 
tion for  injection  into  the  ra- 
dio-carpal joint  is  found  at 
6  millimetres  above  the  centre 
of  aline  connecting  the  extre- 
mities of  the  styloid  processes 
of  the  ulna  and  radius. 


AYith  this  indication  you  will  know 
how  to  introduce  a  fine  needle  into 
the  interline. 

Yerv  often,  you  will  perceive  on 
the  dorsal  aspect  of  the  hand  some 
projecting  fungosities,  developed  in 
the  culs-de-sac  of  the  synovial  mem- 
brane. It  is  by  means  of  these  pro- 
longations of  the  synovial  membrane 
that  YOU  will  be  able  to  force  your 
liquid  into  the  cavity  (fig.  6o3). 

Remember  that  the  soft  parts  are 
rather  thin  on  the  dorsal  aspect  of  the 
wrist,  and  that  one  ought,  conse- 
quently, to  take  every  precaution  in 
dealing  Avith  the  skin.  AA  e  refer  you 
to  what  Ave  have  already  said  on  this 
subject  Avith  regard  to  the  ankle, 
Avhere  the  situation  is  identical. 


Ankylosis  o-f  the  Wrist.      Here 

again,  the  best  treatment  for  ankylosis  is  the  preventive  treat- 
ment. If  vou  treat  the  Avhite  sAvelling  by  means  of  injections, 
Avithout  plaster,  the  Avrist  will  not  become  ankylosed.  I  have 
never  seen  ankylosis  of  this  joint  since  I  haA-e  treated  Avhite 
SAvelling  in  this  Avay. 

But  a  patient,  treated  elscAvhere,  may  come  to  you  Avith  an 
ankvlosis  alreadv  established.      If  it  be  fibrous,  you  Avill   treat 


Wlliri'     SWELLlNn    OF    THE    HAM)    AM)    FINGEUS  503 

it  by  slifihl  inclhocls  :  massage,  ballis;  ;iii(l  yni  will  leave  ihe 
patient  himself  to  carry  out  willi  his  sound  liancl  some  gentle 
movements  (five  or  six  silliugs  dails  of  icn  minutes  each),  the 
fore-arm  being-  immobilisetl  on  llie  lable  l)\  anollier  person,  or 
by  means  of  a  slrap. 

II'  the  ankylosis  is  osseous,  leave  it  alone  '. 

2"'   White  Swelling  of  the  Hand  and   Fingers. 

One    sees,  at  fig.  602,  the  situation   of  the  interline  of  the 
medio-carpal  articulation . 

These  s\Yellings  ought  to  be  attacked  by  injections  in  small 


Fig.    Go3.  —  Point  of  penetration  of  the  needle.     But  one  does  not  need   to  force  the 
needle  so  far  as  is  represented  here. 

doses,  at  intervals,  made  each  time  at  a  different  place,  and  in 
such  a  way  as  to  keep  the  skin  Avhole  whilst  attacking  the  lesions. 
Thinking  always  of  the  integrity  of  the  skin,  it  is  in  this 
Avay  that  one  ought  to  treat  spina  ventosa.  1  mention  this  in 
passing,  though  it  does  not  enter  into  our  present  study,  since 
it  is,  at  any  rate  at  its  onset,  a  disease  of  the  diaphyses  of  the 
phalanges  rather  than  of  their  joints  (see  Spina  Ventosa, 
Chap.  xix). 

1.  Nevertheless,  it  has  happened  to  me  to  interfere  personally  in  a  case 
of  complete  ankylosis  in  a  young  lady  from  Rotterdam,  where,  by  a  non- 
surgical operation  (under  chloroform)  I  broke  down  the  osseous  adhesions. 
I  saw  the  movements  return  completely,  thanks,  I  ought  to  say,  to  a  conse- 
cutive treatment  of  several  months;  a  treatment  very  gentle  and  very  metho- 
dical, carried  out  by  a  skilful  and  well-informed  masseur,  my  regretted  friend, 
D'  Fourriere. 


564 


CONVALESCENCE    AFTER    WHITE    SWELLING 


Ankyloses  of  the  fingers  are  treated  like  those  of  the  wrist 
(see  above) .      Do  not  interfere  with  osseous  ankyloses  ^ . 

CONVALESCENCE  AFTER  WHITE  SWELLING 

Read  again  Avhat  we  have  said  about  the  convalescence  of 
hip  disease,  which  is  merely  a  white  swelling  of  the  hip-joint 
(see  Chap.  vi). 

By  what  signs  would  one  recognise  that  a  white  swelling 


Fig.  6o4.  —  White  swelling  of  the  wrist.     Deformity  of  the  dorsal  region. 

is  cured P  —  By  there  being  no  appreciable  fungosities,  and 
there  being  no  longer  any  pain. 

The  disappearance  of  pain  on  pressure  is  the  clinical  cri- 
terion of  cure. 

From  this  time,  reckon  again  from  5  to  6  months  as  a 
minimum  before  thinking  of  the  anatomical  cure.  After  these 
5  or  6  months  leave  the  joint  to  itself  to  recover  its  normal 
functions,  by  freeing  it  of  all  apparatus  outside  walking  exer- 
cise, unless  you  wish  for  ankylosis,  in  Avhich  case  you  Avill  keep 

I.  Here  again,  nevertheless,  I  have  obtained  a  complete  result  in  a  child 
from  Paris  who  had  an  osseous  ankylosis  of  two  phalanges  of  the  thumb. 
Four  months  after  the  forcible  breaking  down  of  the  ankylosis,  a  good  result 
was  obtained,  thanks  again  to  D"^  Fourriere. 


CONVAI,ESCENCE    AFTER    WHITE    SWELLING  o(J5 

on  the  apparatus  for  a  long  lime.  And,  it  is  necessary  to  look 
for  ankylosis  in  all  cases  where  preservation  of  movements  gives 
rise  to  persistent  pain  or  allows  a  deviation  to  be  reproduced. 

AVc  repeat  that,  when  it  is  a  question  of  choosing  between  a 
good  position  and  mobility,  it  is  the  laller  which  must  be  sacri- 
ficed. 

To  sum  up,  as  lo  ^^  hite  swellings  of  ide  lower  extremity  : 

Do  not  place  your  patient  on  his  feet  until  the  tuberculosis 
is  cured,  that  is,  until  there  is  no  pain  (for  six  months). 

You  will  not  discontinue  all  apparatus  until  a  good  posi- 
tion is  preserved  naturally. 

Duties  of  the  Practitioner  during  Convalescence. 

Your  role  is  not  finished  yet.  It  is,  for  more  than  a  year, 
quite  as  important  as  it  was  during  the  active  period  of  the 
disease. 

But,  alas !  there  are  practitioners  who  take  no  more  interest 
in  the  patient  when  the  pain  or  puffiness  of  the  articular  region 
has  disappeared. 

They  do  not  know  that  they  have  still  a  double  duty  to  fulfil. 

i"  duty.  —  The  practitioner  ought  to  return  the  patient  to 
his  ordinary  life  gradually,  in  order  to  avoid  a  relapse,  or  more 
exactly,  a  revival  of  the  disease.  In  order  to  do  that  he  must 
watch  over  the  general  condition  of  the  patient  and  the  state  of 
the  joint. 

2"''  duty.  —  He  ought  to  watch  over  the  functional  result 
obtained;  to  prevent  the  good  result  being  compromised  or  les- 
sened, and  on  the  contrary,  to  help  on  improvement,  by  all 
the  means  in  his  power. 

I  St  duty.  —  To  prevent  a  Relapse  or  a  Recurrence 

We  can  only  repeat  here  what  we  have  said  Avith  regard  to 
hip-joint  disease.  One  ought  to  take,  for  a  much  longer  time, 
precautions  of  the  general  and  local  order.  I  mean  by  pre- 
cautions of  the  general  order  that  one  must  not  hasten  the 
return  of  the  cured  patient  to  the  city,  or  to  the  surroundings, 


566  CONVALESCENCE    AFTER    WHITE    SWELLING 

often  unhealthy,  Avhere  he  was  taken  ill.  It  is  necessary  to 
attend  to  his  diet  and  his  hygiene  and  to  avoid  all  possible 
contagion. 

From  the  local  point  of  view  :  one  cannot  at  once  impose 
upon  a  joint  Avhich  has  just  recovered,  the  same  Avork  that  one 
would  upon  a  joint  Avhich  has  always- been  sound.  It  is  only 
gradually  that  its  natural  functions  will  return. 

One  realises  that  the  upright  position,  or  walking,  if  it  is 
a  question  of  the  lower  limbs,  can  only  be  maintained,  at  the 
beginning,  for  a  few  minutes. 

In  certain  cases,  it  is  necessary  to  help  the  Aveak  joint  by 
enclosing  it  in  an  apparatus,  plaster  or  celluloid,  Avhich  will 
ensure  its  rest.  The  support  of  two  sticks  is  useful  for  wal- 
king, and  for  six  months  one  may  even  use  crutches,  which 
relieve  the  knee  or  the  foot  of  the  Aveight  of  the  body.  Such 
are  the  means  of  preventing  the  return  of  the  disease,  or  at  least 
of  rendering  a  return  as  rare  as  possible ;  for  a  debilitating 
disease,  appearing  unfortunately  soon  after  the  cure,  an  eruptive 
fever,  bronchopneumonia,  etc.,  or  again,  a  traumatism,  a  sprain 
or  a  bloAv  on  the  joint,  might  re-kindle  the  tuberculous  focus, 
whatever  has  been  done  so  far.  The  parents  should  fly  from 
all  foci  of  contagion,  and  religiously  guard  the  child  from  all 
chances  of  injury  and  from  all  fatigue. 

2"^  duty.  —  To  maintain  and  improve  the  functional 
result.    —  Take  care,  nevertheless,   of  all  unseasonable    zeal. 
Adhere  to  the  simple  methods  :   massage,  baths,  teaching 
to   walk. 

At  the  same  time,  do  not  have  recourse  even  to  those  simple 
methods  until  from  six  to  ten  months  at  least  after  the  real 
cure  of  the  white  swelling. 


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